2015Student Application

(Type or print clearly)

First Name: ______Last Name:______

Organization: ______

Work Address: ______

Work Phone: ______Cell Phone: ______

Email: ______

Current Job title: ______Paid _____ orVolunteer_____

Number of years of direct victim service ______From: ______To: ______

Education/Degree(s): ______Year: ______Major: ______

1. Select the single category that best describes the type of organization you represent.

Criminal Justice CommunityNonprofit Additional Organizations

_Police-based _Homicide_ Faith-based

_Court-based_Domestic Violence_ Hospital/Medical

_ Corrections-based _Sexual Violence_ Media

_ Military-based_Child Abuse_ Government (please list)

_Juvenile-based_Stalking_Other (please list)

_ Other: (please list)_Property Crime

_ Economic

_Other: (please list)

2. Please indicate the types of victims you primarily serve.

_ Assault/Robbery _ Immigrant Populations _Victims with Physical Disabilities

_ Child Abuse _ Property Crime _ Victims with Mental Disabilities

_ Domestic Violence _ Economic / Fraud_Other: (please list)

_ Drunk Driving_Sexual Assault

_ Elderly Victims_Teens and Adolescents

_LGBTQ _Trafficking

3. Please indicate the types of services you primarily provide for crime victims in your current position. (Checkno more than five boxes)

_24-Hour Hotline_Information/Referral _Shelter

_Child Care_Legal/Civil Advocacy _Short-Term Counseling

_Comp. Claim Assistance_Long-Term Counseling_Victim Impact Statement

_Court Accompaniment_Medical Advocacy _ Other: (please list)

_ Criminal/Juv. System Advocacy_ Notification

_ Crisis Intervention_ Restitution Assistance

4. Briefly summarize your current or previous experience assisting crime victims in the last three years. Provide position, responsibilities and dates of service from most recent to past.

Position: From: To:

Organization:

Responsibilities:

Position: From: To:

Organization:

Responsibilities:

Position: From: To:

Organization:

Responsibilities:

5.Why do you want to participate in the DCVAA Cultural Competency:The Asian-Pacific Islander Community training? How will your participation benefit you professionally, your organization, and your community?

Commitment Statement

6. Successful applicants must commit to the entire 16-hour (2-day) training.Tuitionisincluded at no cost. Meals are not included.Please signify your commitment to complete the full 16-hour (2-day) training.

______

Applicant print name and sign Date

______

**Supervisor print name and sign Date

** Supervisor’s signature consents to applicant’s participation of 16 hours of DCVAA required attendance during regular work hours.

The application deadline is June 5, 2015.Email signed applications to : Subject line: 2015 DCVAA Cultural Competency Asian Pacific Islander Community

DC Victim Assistance Academy

Office of Victim Services and Justice Grants

441 4th Street NW #727N

Washington, DC 20001

DCVAA Student ApplicationPage 1

Office of Victim Services and Justice Grants∙ 441 4th Street NW ∙ Suite 727N ∙Washington DC 20001∙ (202) 727-0605