NAZARETH LIFE MINISTRIES

 

Crisis Pregnancy Outreach Center

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Volunteer
Referral Volunteer Employment

 

 

VOLUNTEER APPLICATION

Name:      Phone: (H)     (W)                                                                                                                                            999 999 9999                                            999 999 9999

Address:       Date of Birth: MM/DD/YYYY

In the event of an emergency, please contact:

Relationship:                Phone: 999 999 9999

Do you have a Drivers License  Yes  No

(We will need to do a background check and MVR before you may transport youth)

 

 

How would you like to volunteer your services to Nazareth Life Ministries:

Please describe your background qualifications for the service you wish to perform.  (Education, professional license, experience, etc.)

Is there a particular type of volunteer work in which you are interested?

Work one-on-one with a young woman as a mentor volunteer. Provide job opportunities for our clients.
Give a lecture or class on a specific topic/skill Office/secretarial work
Outdoor work (Gardening, yard work, etc.) Maintenance/Repairs.
Other (Please specify)  

At what times are you available to volunteer? (Please check all that apply.)

Flexible, depending on need  
Mornings Weekday
Afternoons   Weekend

 

Please list 3 non-relative personal references:

1. Clergy or Professional Reference.

Name:                                                                    Phone:

Address:                                                                Occupation:

                                                                             Relationship:

2. Personal Reference.

Name:                                                                    Phone:

Address:                                                                Occupation:

                                                                             Relationship:

3. Personal Reference.

Name:                                                                    Phone:

Address:                                                                Occupation:

                                                                             Relationship:

You are responsible for contacting these references and asking them to send a letter of recommendation on you behalf to:

Annalea Celio - Outreach Coordinator

Nazareth Life Ministries

P.O. Box 204

Macon, GA 31202-0204

 

 

Please answer all of the following:

1. Do you use illegal drugs?    Yes   No
2. Have you ever been convicted of a criminal offence?   Yes   No
3. Have you ever been arrested or convicted for use or sale of drugs?   Yes   No
4. Have you ever been hospitalized or treated for alcohol or substance abuse?   Yes   No
5. Have you ever been arrested or convicted of child neglect or abuse?   Yes   No
6. Has your driver's license ever been suspended or revoked?   Yes   No
7. Other than the above matters, is there fact or circumstances involving you or your background that would call into question your being entrusted with the supervision, guidance, and care of young people? (if yes explain)   Yes   No
8. Have you ever been sued in a Court of Law, and, if so what were the circumstances?   Yes   No
9. Have you ever been the subject for a Police Dossier, and, if so, where?   Yes   No

 

 

PLEASE READ BEFORE SIGNING

 I understand that:

the information that I have provided may be verified, and I give permission to Nazareth Life Ministries to make inquiry of others concerning my suitability to act as a Nazareth Life Ministries volunteer, including the right to conduct a criminal background check.

in the course of volunteering for Nazareth Life Ministries, I may be dealing with confidential information and I agree to keep said information in the strictest confidence.

the relationship between Nazareth Life Minsistries and volunteers is an 'at will' arrangement, and that it may be terminated at any time without cause by either the volunteer or Nazareth Life Ministries.

my role as a volunteer, is under the supervision and direction of Nazareth Life Ministries staff, with whom I will cooperate completely. I will not engage in counseling the residents of Nazareth Life Ministries, nor will I become involved in discharge planning for any resident unless invited to do so by staff.

I grant Nazareth Life Ministries permission to use my likeness, voice, and words in TV, radio, film, or in any form to promote activities of Nazareth Life Ministries.

I affirm that I have read the above and that the information I have given is true and complete and that if I circumstances change in areas above I will contact Nazareth Life Ministries prior to any further volunteer activity.

Signed:                                                                        Date:

 

 

 

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Last modified: 04/27/06