Teal Green Heart Advocate Form

Advocate Application

First name

Last name

Complete address

City

Zip code/Postal code

State

Country

Home or cell phone number

Phone country code (If outside of U.S.)

Gender

Age

Birthdate (mm-dd-yyyy)

Highest education

Do you currently hold a leadership position at your church/faith-based organization (FBO) or have previous leadership experience?

Describe your leadership experience

Are you comfortable assisting sexual assault and/or rape survivors that are children, teenagers, males, females, and/or transgender from the lgbtq community?

Have you ever been accused and/or convicted of a sexual or drug related crime, and/or accused or convicted of a criminal offense that was in any manner related to an sexual offense?

Please explain the accusation and/or conviction(s)

Please explain why you desire to become an advocate for the TGH initiative?

Are you a sexual assault or rape survivor?

Have You ever Received Any Medical Treatment, mental health medications, And/Or Rape Counseling

Have you ever report or accompanied a person to law enforcement to report sexual assault and/or rape offense to a law enforcement agency?

If anyone every confided in you that they were going to hurt themselves or someone else, what would you do first?

Have you ever felt, attempted, or thought about suicide?

Do you have any advocacy experience?

Are you apart of the Brain Squad on social media?

Did you report the sexual assault or rape offense to law enforcement?

What is title of the person who is recommending you:

FBO leader’s Full Name

What is the doctrine taught at your FBO?

Recommendation
Is your faith-based organization (FBO) aware, registered, and/or affiliated with the Teal Green Heart (TGH) initiative?

FBO Complete Physical Address

Country

FBO telephone number w/country code

FBO leader’s title and name

FBO’s cell telephone number w/country code

FBO’s email

Name of the FBO’s administrator referring you

FBO administrator’s email

FBO Telephone number with Country code

Are you an administrator at this FBO?

Do you regularly attend this FBO?

Which days of the week are the FBO’s doors open to the public

Does FBO operate in a private home?

Will you have access to a private office at this FBO facility to meet with sexual assault or rape survivors in a completely discrete place?

Does your FBO administration know you are applying to become a Teal Green Heart advocate?

Are you aware TGH provide advocacy certification?

Are you aware this advocacy opportunity includes a stipend (monetary compensation)?

If you have completed the rape trauma advocacy certification, please upload copy of your certification here

Disclosure: we will donate money to the faith-based organization, specifically for the organization to compensate you for your time and assistance to help the general public.
How did you hear about the Teal Green Heart initiative?

I certify that I have read and understand the purpose, responsibilities, and commitments as outlined on the Teal Green Heart Duty and Commitment table, and I am willing to work to meet the requirements of the positions that I indicated above.

Print full name

Upload your signature here

Date (mm-dd-yyyy)

I agree

I understand the purpose, responsibilities, and commitments of the Teal Green Heart initiative as outlined at the Duty and Commitment table at www.jhrc.org and the advocacy position the applicant has applied for and agree to support the applicant in their efforts to meet these requirements. For example, assisting with providing a private office or room for the advocate to communicate with individuals in need of help associated with sexual assault and/or rape services.

Title

Date (mm-dd-yyyy)

Print full name

Upload your signature here

Please have FBO leader complete the section:

I understand the purpose, responsibilities, and commitments of the Teal Green Heart (TGH) initiative as outlined at the Duty and Commitment table at www.jhrc.org is to provide a safe haven for victims of sexual assault and/or rape. I understand and agree to that advocacy includes serving the LGBTQ community and not just church or FBO members. I agree to accept donation and/or a stipend and to pay the funds to individual(s)/advocate assigned to advocate position. I agree and understand; the applicant has applied to help rape and sexual assault survivors at our FBO location. I agree this candidate is in good standing at our FBO. I agree at any time to provide the advocate with a private and confidential meeting room or closed-door space to have meetings with survivors. I understand that I am NOT allowed to be present during these meetings. I understand the advocate much must complete a certification and a copy must be kept in a file at the FBO with the advocates completed application. I agree to keep all matters completely confidential regarding the applicant and all survivors that seek advocacy services. I agree to support the applicant in their efforts to meet all these requirements. For example, rape can occur on any day and at any time… Therefore, you agree to make sure the advocate has access to assist an advocate with providing a private office or room at any time for the advocate to privately communicate with individuals in need of help associated with sexual assault and/or rape services.

I have provided truthful and accurate information and agree to the TGH Initiative rules, regulations, and terms.