Veteran Participant Application 2017
Name ________________________________________________________________________________________________________________________________________________
First
Middle Initial
Last
Address
_______________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Primary phone ___________________________________________________
[ ] cell
[ ] home
Primary email _____________________________________________________________________________________________________________________________________
Date of Birth:_______/________/________
Ethnicity [ ] Asian
[ ] White
[ ] male
[ ] Black/African American
[ ] female
[ ] Hawaiian/Pacific Islander
[ ] American Indian (tribe__________________________________________)
What military branch did you serve in?
[ ] Navy
[ ] Army
[ ] Marines
[ ] Hispanic/Latino
[ ] other __________________________________________
[ ] Coast Guard
[ ] Air Force
What years did you serve? ________________________________________________________________________________________________________________________
A valid DD214 from the Veteran’s Administration is required. Have you attached a copy? [ ] Yes
Employer__________________________________________________________
Job title________________________________________________________________
Does your employer support volunteerism through paid time off to volunteer, cash match to volunteer site, other?
If yes, please describe
_______________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
Education ___________________________________________________________________________________________________________________________________________
Community affiliations ____________________________________________________________________________________________________________________________
Have you ever been convicted of a felony? [ ] Yes
[ ] No
Deployment Information
Soul River Inc is hosting seven (7) deployments for 2017. One (Urban Native Waterlife™ Explorations at Oxbow Park) is for Youth
Participants only, therefore it is not listed. The deployments vary in group size and location. We strive to select a diverse group per
outing in regards to age, gender, ethnicity, skills and abilities. Please check the deployments that you would be interested in
participating in, keeping in mind the dates. Please check at least two in case one deployment fills up. Selections for outings will be
made and communicated by March 18th.
[ ] Urban Native Waterlife™ Explorations: Willamette River, OR (May 26-29th)
[ ] Angler’s Quest – Quinault Indian Nation: Tahloah, WA (June 2-4th)
[ ] Everglade’s Wonder-of-Science Angling Exploration: Florida Everglades (June 18-24th)***
[ ] Angler’s Quest – Kitchi-gami: Marquette, MI (July 18-24th)***
[ ] Cross Cultural Science Expedition – Arctic Village: Arctic (July 25 – August 3rd)***
[ ] Angler’s Quest – Owyhee Canyonlands: Nyssa, OR (August 18-21st) pending funding
***Veterans selected for this expedition will be expected to do the following once they have been selected:
- Participate in a one-day Meet-n-Greet leadership skills clinic (May/June)
- Participate in one follow-up SRI events representing the expedition (i.e., Celebration Wild Steelhead, Annual Gala &
Auction)
Each deployment has specific curriculum that teaches specific skills that you will be required to support and/or lead. What are your
skills?
[
[
[
[
] fly fishing [ ] fly tying
[ ] fire building
[ ] orienteering/land navigation
[ ] outdoor leadership instruction
] outdoor wilderness survival
[ ] story-telling
[ ] knot tying
[ ] backpacking
[ ] tracking
] plant/tree identification
[ ] conservation education [ ] river ecology
[ ] entomology
[ ] geology
] shelter building
[other] _________________________________________________________________________________________________________________
Certifications, Licenses, and Permits
Please list certifications, licenses, and permits you currently hold (i.e., EMT, WFR, LPC/LMFT, Basic First Aid, CPR, Lifeguard,
Fishing License, Boating License, Guide License, Hunter Safety Instructor, Archery, Ropes Course, Food Handlers Permit, etc.)
Name of Certification, License, and Permit
Expiration Date
Issued State
Were you a 2016 SRI Participant?
If so, you can skip Supplemental Questions 1-5, as well as the References section. Please answer the following question ONLY IF
YOU WERE A 2016 PARTICIPANT:
What was the most rewarding part of your 2016 deployment experience? What do you hope to gain this year?
________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________
Please sign agreements on Page 5 and submit.
Supplemental Questions
1.
Why are you interested in participating in Soul River Inc deployments?
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
2.
What is your experience working with at-risk youth?
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
3.
What types of coping strategies do you use to deal with daily stressors?
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
4. What character qualities do you possess that would make you an asset to Soul River Inc deployments and events?
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
References
List three individuals able to give character references. If you have a mental health practitioner that you visit on a regular basis,
please list them as a reference. One reference can be a spouse or family member close to you.
Mental Health Practitioner/Other
Name______________________________________________________________________________________________________________________________________________
Relationship to Applicant _________________________________________________ Length of time known _____________ [ ] months
[ ] years
Phone __________________________________________________ Email address ________________________________________________________________
ADMINISTRATIVE USE ONLY
_____________date of contact
_______________recommends
Personal Reference Contact/Spouse or Family member
Name______________________________________________________________________________________________________________________________________________
Relationship to Applicant _________________________________________________ Length of time known _____________ [ ] months
[ ] years
Phone __________________________________________________ Email address ________________________________________________________________
ADMINISTRATIVE USE ONLY
_____________date of contact
_______________recommends
Personal Reference Contact
Name______________________________________________________________________________________________________________________________________________
Relationship to Applicant _________________________________________________ Length of time known _____________ [ ] months
[ ] years
Phone __________________________________________________ Email address ________________________________________________________________
ADMINISTRATIVE USE ONLY
_____________date of contact
_______________recommends
Participant Agreements
BACKGROUND CHECK - Permission for a valid background check in processing my application, Soul River Inc. may verify all
information provided by me and/or may procure or have prepared a consumer or investigative report for the purpose of obtaining
information on prior employment, my character, general reputation, and criminal record. Such checks will include criminal
background, fingerprinting and driving records checks. Criminal background checks will be done on the state and federal level
(FBI). I understand that upon written request to Soul River Inc., I will be informed whether an investigation report was requested
and given full information as to the nature and scope of this investigation.
Signature_____________________________________________________________________ Date_______/________/________
MATERIALS CREATED/PHOTO & VIDEO RELEASE - I understand that all materials created during volunteer activities including
artwork, writing, film, photographs, videos, and other are the sole property of Soul River Inc. and cannot be taken or used without
expressed consent from Soul River Inc..
Signature_____________________________________________________________________ Date_______/________/________
CONFIDENTIALITY AGREEMENT - Each volunteer may be privy to confidential information about the program participants and
their families, Soul River Inc. staff, process, issues, and the organization in general. As an organization, Soul River Inc. does
everything possible to protect the confidentiality of each participant, staff member, and volunteer. However, it is the responsibility
of each person who is a part of the organization, paid or volunteer, to respect these confidences. Some information we deal with at
Soul River Inc. is sensitive in nature. We treat this information with care and respect, and it is important that this information is
held in confidence. Confidential information includes, but is not limited to, the following: youth full names, veteran full names,
records or medical information, family information and experiences, donor information, management, plans, contracts. Anyone
who violates the confidentiality required by Soul River Inc. will be asked to resign as a volunteer. I understand that the work, the
youth and veterans with whom I volunteer entrust the program with possible confidential information. With this in mind, I will
protect their privacy and confidences to the best of my ability except in an effort to protect the participants from harm. I will not
discuss them or their family matters, or any work processes or procedures, with persons or agencies outside Soul River Inc.. If
asked to share stories about Soul River Inc. youth, I will seek advice from the Program Director or the Executive Director. I fully
understand the importance of protecting the confidentiality of Soul River Inc. I also understand the importance of protecting Soul
River Inc. youth from harm. By signing this agreement, I agree to keep the confidentiality entrusted to me by Soul River Inc. and the
organization in general.
Signature_____________________________________________________________________ Date_______/________/________
Please scan and send completed application (including the final page for administrative use only) to
[email protected] or mail to Soul River Inc., Application, 1926 N. Kilpatrick St., suite B, Portland, OR 97217. WE
WILL NOT ACCEPT APPLICATIONS PERSONALLY DROPPED OFF AT OUR OFFICE.
PLEASE RETAIN A COPY OF THIS APPLICATION FOR YOUR REFERENCE