Please provide the information below and press the 'Submit' button at the bottom of this page.
We will contact you as soon as possible   -   Thank you for your interest in the HAC.



 
  Your First Name   Your Last Name
    Female   Male  

  Home Phone   Cell Phone   Other Phone   eMail Address
       

  Home Address   City  State   Zip
       

  Your Profession
 

  Emergency Contact   Relationship   Home Phone   Cell Phone
       



  Background Information:


  What are your reasons for wanting to volunteer with the HAC?

  What would you like to gain from your Member/Volunteer experience?

  Please list your special hobbies, skills, computer skills, and talents:

  Please list your volunteer work experience:

  What languages, other than English, do you speak fluently?

  How did you hear about our organization?

  Have you ever been convicted of a crime? No   Yes   If yes, please explain below.
  (You may omit minor traffic offenses, any convictions which have been sealed, expunged, or statutorily eradicated, convictions more than two years old
for marijuana related offenses for personal use, and misdemeanors for which probation was completed and the case judicially dismissed.)

Advisory
A check of the applicant's criminal history may be made to verify responses to the above questions for the sole pupose of ensuring the safety of our staff, volunteers, and visitors. No applicant will be denied volunteer or member status solely on the grounds of a conviction of a crime. The nature of the offense, the date of the offense, the surrounding circumstances, and the relevance of the offense to the position requested, will be considered.



  Please List 3 References:
  Reference Name   Relationship   Phone
     
     
     



Photo Release Consent

If you have lost a loved one to Heroin, the Heroin Awareness Committee requests your permission to use your loved one's picture on our materials. We want to make sure we preserve and honor their memory in the most respectful and effective manner possible. The HAC wants to ensure you, the family, that we will be sensitive to the unique and sometimes challenging situations a passing of this nature can bring.

  If you wish to allow the HAC to use your loved one's picture on our materials, please provide the following information:

  How do you wish us to recognize your loved one?    Picture, Name, and Date of Birth/Death   Picture Only   No Consent or Loss

  How would you like us to present his/her name?

  Please enter any special instructions or information you would like us to know prior to posting a picture and/or information.

  Please check each method in which we may use the materials you have consented.

The HAC Website
Flyers, Brochures, and other forms of printed materials.
Presentation Materials (PowerPoint, etc.)
Media Information (Public Service Announcements, Commercials, Billboards, Videos, etc.)


If at any time you wish your loved one's image to no longer be used, please notify us and we will immediately remove their picture from our website and no longer use their image on future materials. Due to printing costs, we will continue to distribute existing printed materials, but in the mean time, we will remove their image from our "active" list.


--- Click Here to Send Photo and Accompanying Message for our Memorials Page ---




Application Acknowledgement

By clicking the "Submit" button below, I certify that the information I've submitted on this application is true and complete. I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected. I further understand that my Active or Volunteer status may be terminated with or without cause, and with or without notice, at any time. In consideration of my application, I also agree to adhere to the policies and regulations of the Heroin Awareness Committee and that failure to do so may result in termination.
  - OR -  
 


The HAC does not support, endorse, or provide referrals to any medication, practitioner, or treatment program relating to heroin or opiate addiction. The HAC recommends that you call 911 in an emergency situation. Seek the advice of a medical professional to determine the proper course of treatment for your specific circumstance.  If you have health insurance, contact the customer service line for your specific carrier as they are able to help find providers in your area based on your particular coverage.