| Select Preference (Indicate Numerical Order of Choices) _____ California State University-Fresno, Fresno, CA (June 8-13, 2003) _____ Washburn University, Topeka, KS (June 8-13, 2003) _____ Medical University of SC, Charleston, SC (June 22-27, 2003) |
| Note: Please type Application Form | |
| Name_________________________________________________ | Date______________________________________ |
| Organization________________________________________________________________________________________ | |
| Work Address_______________________________________________________________________________________ | |
| Work Phone #(_____)_____________________________________ | Fax #(_____)________________________________ |
| Home Address______________________________________________________________________________________ | |
| Home Phone #(_____)_____________________________________ | E-mail_____________________________________ |
| Current Position_______________________________________ | Managerial Paid Volunteer |
| Education/Degree(s)___________________________________ | Year___________Major__________________ |
1. Select the jurisdiction and one category below that best describes the type of organization you represent:
Jurisdiction: Federal State Local Tribal International
| Criminal Justice-based | Community/Nonprofit-based | Additional Agencies |
| Police/sheriff-based | All victims | Youth Services |
| Prosecution-based | Sexual Assault | Native Americans |
| Court-based | Domestic Violence | Religious |
| Probation-based | Child Abuse | Hospital/Medical |
| Corrections-based | Drunk Driving | State VOCA Assistance Staff |
| Parole-based | Homicide Support | State Victim Compensation Staff |
| Juvenile Justice-based | Missing/Exploited Children | Other_____________________ |
| Elderly Victims |
2. Please indicate the types of victims that you primarily serve below. (Check no more than three boxes)
| Domestic Violence | Drunk Driving | Native Americans |
| Sexual Assault | Assault/Robbery | Property/Economic Crime/Fraud |
| Child Abuse | Elderly Victims | Special Needs/Victims with Disabilities |
| Survivors of Homicide Victims | Missing/Exploited Children | Other______________________ |
3. Please indicate the types of services that you primarily provide for crime victims in your current position. (Check no more than five boxes)
| Crisis Intervention | Criminal Justice System Advocacy | Legal Advocacy |
| 24-hour Hotline | Court Accompaniment | Information/Referral |
| Emergency Medical | Restitution Assistance | Training and Technical Assistance |
| Shelter | Notification | Transportation |
| Short-term Counseling | Victim Impact Statement Assistance | Child Care |
| Long-term Counseling | Compensation Claim Assistance | Other_______________________ |
4. Please briefly summarize your current and previous experience assisting crime victims and other relevant employment in the last five years. Provide position, responsibilities, and dates of service in chronological order.
| Position_____________________________________________________ | From___________To____________ |
| Organization__________________________________________________________________________________ | |
| ____________________________________________________________________________________________ | |
| Position_____________________________________________________ | From___________To____________ |
| Organization__________________________________________________________________________________ | |
| ____________________________________________________________________________________________ | |
| Position_____________________________________________________ | From___________To____________ |
| Organization__________________________________________________________________________________ | |
| ____________________________________________________________________________________________ | |
5. Please briefly state why you want to attend the National Victim Assistance Academy and how your participation will be of benefit to you (professionally and personally), your organization, and your community. Please include any additional, brief information that you believe is important for consideration during the selection process.
6. If accepted for the Academy, I am interested in receiving three units of academic credit for a fee of $120:
Undergaduate Graduate
I am also interested in receiving information regarding possible scholarship for tuition:
Yes No
7. By signing below, please signify your commitment to attend the full course and make all travel arrangements accordingly.
| ___________________________________________________________________________________________________ | |
| Name (Typed) | Date |
8. Please mail the original and two (2) copies of your completed application form, with signed commitment, and two (2) written letters of recommendation, to:
OVC Training and Technical Assistance Center
10530 Rosehaven St., Suite 400
Fairfax, Virginia 22030
Toll Free: (866) OVC-TTAC
Your application package must be received no later than April 18, 2003.
(This is a deadline extension from the previous April 7 date.)
While all Academy sessions will be conducted in English, the National Victim
Assistance Academy warmly welcomes international applicants