Circles Douglas County Circle Leader Application
Please complete this application if you are interested in becoming an leader in the Circles program. If you have any questions, please email circlesdc@fpcdouglasville.org.  You will receive a response within five business days of receipt of your application. Thank you! 
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Full Name *
Birthdate (Ex: month, date and year- 01/01/2024) *
Home Address *
Cell Phone Number with Area Code *
Email Address *
Are you currently employed?  *
If you answered yes, please list the name and location of your employer. 
What is your marital status?  *
Preferred Method of Contact *
Required
Time of day you are available *
Circles of Douglas County meets weekly on Tuesday nights from 6:00pm-7:30pm.  Dinner is served and childcare is available. Are you available on Tuesday nights?  *
Do you have children in your household age 18 or under?  *
If you answered yes to the question above, please list the names of your children along with their ages (18 and under).
Please list anyone else living in your home and their relation to you.  *
An individual at 185% of the Federal Poverty Line (FPL) earns $27,861.A person with 1 dependent earning 185% of the FPL, earns $37,814. A person with 2 dependents, earning 185% of the FPL, earns $47,767 A person with 3 dependents earning 185% of the FPL earns $57,720. Do you live at or below this guideline?  *
Are you at least 18 years of age? *
Do you speak and read English?  *
Are you able to attend weekly meetings?  *
Are you motivated to learn and apply new ideas?  *
Do you belong to any groups or community organizations?  *
If you answered yes, please the groups or community organizations:
Are you willing to build relationships across class and cultural lines?  *
Are you supported and encouraged by family to participate in Circles?  *
Have you been in recovery for at least six months if you have a history of alcohol or other addition? *
Are you in a relatively stable situation? (not currently homeless, dealing with domestic or drug abuse) *
Background checks are required for participation in any activities where children may be present. This information also may help Circles support you better if you are experiencing barriers related to having a record, such as voting rights, housing and employment. Have you ever been convicted of a felony?  *
Do you currently have a court case pending?  *
Do you have any active warrants? *
How did you hear about Circles?  *
What interests you about becoming a Circles Leader? *
Name and phone number of an emergency contact person *
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