Your Name: (required)

Email: (required)

Telephone: (required)

Your Address: (required)

State: (US)         Province: (Canada)        

Name that you will use as Regional Team Helper:

Date of Birth    
Gender: FM      Marital Status: DivorcedMarriedSeparated
Any issues with confidentiality? NoYesOther
If yes, please explain:

First names of children/ages:

What would you like to share about your ex?

Give a brief description of your divorce and/or custody situation:

What is your main goal in applying to be a Regional Team Helper?

How much time can you commit each week?
1-2 hours3-5 hours5-10 hoursWhatever you need
(Have you thoroughly considered the time and dedication that is involved for this position?)

Do you see your commitment level changing?
If yes, please explain:

Tell me your top five strengths as a leader:

Anything else you would like to share with us?

Thank you for your interest in becoming an Regional Team Helper.
Please leave this field empty.