Get Involved in Potter's House

Involvement Application

Thank you for your interest in Potter's House! Please complete the following information to help us get you involved in Life Together programs in Fayetteville, Arkansas.

Note:
If you are interested in volunteering at the Thrift Store, you do NOT need to complete this application. Simply send an email to chad@phnwa.com with your name and availability.

1. How are you hoping to become involved in the Potter's House community? (Click all that apply).

[NOTE: All interest forms will be sent to the appropriate staff based on interest. Each program has limited space. When there is available space, staff will reach out to the parents/guardians to schedule a meeting to discuss the eligibility and requirements for each participant in order to assess if the program is the best fit for Potter's House and for the family in interest.

I'm interested in volunteering.
I'm interested in getting my children involved in the Small Group program.
I'm interested in getting involved in the Wet Cement preschool (some level of volunteer involvement required by parents in this program - so please be sure to select the volunteer option so we can gather all necessary information.)
I'm interested in getting involved in the Leadership Development program.
I'm interested in getting involved in the Adult Program.
I'm interested in interning.

2. If you have already spoken or corresponded with a Potter's House staff member, please provide the staff members name below:

Please enter an 'other' value for this selection.

3. Please fill out the information below.

First Name

Middle Initial

Last Name

Email This question requires a valid email address.

Phone This question requires a valid number format.

Birthdate *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Gender

4. Address (Where you currently live and/or receive your mail)

Address

City

State

Zip

6. Do you live at this address year round?

7. If you do not live in Northwest Arkansas full time, please provide a mailing address where you can be reached? (i.e. You stay with your parents at another location during University breaks)

Address

City

State

Zip

7. What program(s) are you interested in volunteering for? (Click all options of interest).

Wet Cement Preschool
Small Group Leader
Leadership Development (7th-12th grade)
K-6 Kids Summer Program

Being a Driver or Rider for a Program
Helping with childcare for Adult Program
Unsure, need more information

7. What days and times are you available to volunteer? Write the times in the boxes below for each day.

Mondays Please enter an 'other' value for this selection. * This question is required.
Tuesdays Please enter an 'other' value for this selection. * This question is required.
Wednesdays Please enter an 'other' value for this selection. * This question is required.
Thursdays Please enter an 'other' value for this selection. * This question is required.
Fridays Please enter an 'other' value for this selection. * This question is required.
Sundays Please enter an 'other' value for this selection. * This question is required.

Comments

7. Do you have any experience working with children or teens?

7. Where did you work with children and teens and what responsibilities did you have?

7. Are you looking to volunteer or intern to receive credit for a university class or sorority? *This question is required.

7. If so, please let us know which class or sorority you are volunteering for, how many hours are required, and when the hours are due:

Please tell us why you are interested in becoming a volunteer or interning at Potter’s House.

What strengths do you possess that will assist you during your experience with Potter's House?

How do you hope to grow or learn through this experience?

7. Please list 3 references:

Space Cell	Name	Email	Phone	Relationship
Personal Reference #1 (cannot be a family member)	Personal Reference #1 (cannot be a family member): Name	Personal Reference #1 (cannot be a family member): Email	Personal Reference #1 (cannot be a family member): Phone	Personal Reference #1 (cannot be a family member): Relationship
Business/Professional Reference	Business/Professional Reference: Name	Business/Professional Reference: Email	Business/Professional Reference: Phone	Business/Professional Reference: Relationship
Another Personal or Professional Reference (cannot be a family member)	Another Personal or Professional Reference (cannot be a family member): Name	Another Personal or Professional Reference (cannot be a family member): Email	Another Personal or Professional Reference (cannot be a family member): Phone	Another Personal or Professional Reference (cannot be a family member): Relationship

7. Please provide some information on your educational background.

Current or completed college degree (if applicable)

Minor (if applicable)

Master's Degree (if applicable)

Anticipated Graduation Date (Month & Year) *This question is required.

7. If Potter's House staff needs to contact an emergency contact on your behalf, who should we call?

First Name
Last Name
Relationship to You
Phone Number

8. Since you are looking to involve your family, please provide the information for your spouse/partner. If you have children, this can be secondary parent/guardian (if applicable). This is helpful information for us as we hope to integrate the entire family unit into our Potter's House community.

First Name

Last Name

Date of Birth This question requires a valid date format of MM/DD/YYYY.

calendar

Gender

Email Address

Phone Number

Relationship to You

8. Please provide us with the information for the first child in your household (if applicable).

First Name

Last Name

Current Age

Date of Birth This question requires a valid date format of MM/DD/YYYY.

calendar

Gender

Current School (if applicable)

What grade are they currently in? (If it is summertime, please provide grade they will be entering in the fall).

If you are interested in signing up this child for a Potter's House program, please indicate all that apply below:

8. Do you have another child in your household?

8. Please provide us with the information for the 2nd child in your household.

First Name

Last Name

Current Age

Date of Birth This question requires a valid date format of MM/DD/YYYY.

calendar

Gender

Current School (if applicable)

What grade are they currently in? (If it is summertime, please provide grade they will be entering in the fall).

If you are interested in signing up this child for a Potter's House program, please indicate all that apply below:

8. Do you have a 3rd child in the home?

8. Please provide us with the information for the 3rd child in your household.

First Name

Last Name

Current Age

Date of Birth This question requires a valid date format of MM/DD/YYYY.

calendar

Gender

Current School (if applicable)

What grade are they currently in? (If it is summertime, please provide grade they will be entering in the fall).

If you are interested in signing up this child for a Potter's House program, please indicate all that apply below:

8. Do you have a 4th child in the home?

8. Please provide us with the information for the 4th child in your household.

First Name

Last Name

Date of Birth This question requires a valid date format of MM/DD/YYYY.

calendar

Current Age

Gender

Current School (if applicable)

What grade are they currently in? (If it is summertime, please provide grade they will be entering in the fall).

If you are interested in signing up this child for a Potter's House program, please indicate all that apply below:

8. Do you have a 5th child in the home?

8. Please provide us with the information for the 5th child in your household.

First Name

Last Name

Current Age

Date of Birth This question requires a valid date format of MM/DD/YYYY.

calendar

Gender

Current School (if applicable)

What grade are they currently in? (If it is summertime, please provide grade they will be entering in the fall).

If you are interested in signing up this child for a Potter's House program, please indicate all that apply below:

8. Do you have a 6th child in the home?

8. Please provide us with the information for the 6th child in your household.

First Name

Last Name

Current Age

Date of Birth This question requires a valid date format of MM/DD/YYYY.

calendar

Gender

Current School (if applicable)

What grade are they currently in? (If it is summertime, please provide grade they will be entering in the fall).

If you are interested in signing up this child for a Potter's House program, please indicate all that apply below:

Thank you so much for taking the time to answer these questions.