Mosaic Health Volunteer Application
Date
MM
/
DD
/
YYYY
First / Last name
Email address
Phone number
Address
In what volunteer position(s) are you interested?
How did you hear about Mosaic Health?
Have you ever been convicted of a crime other than a minor traffic offense (even while in the military?)
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Yes
No
If yes, please explain:
What is your reason for seeking to volunteer at Mosaic Health?
Do you consider yourself a Christian? If so, how long have you been a Christian?
If you attend church, please list the church's name and how long you have attended.
As a Christian, what is the basis of salvation?
Please list any areas is which you have served at your church.
Mosaic Health is a life-affirming, Christ-centered organization. Please write a brief statement about how your faith would affect your volunteering.
What special skills, talents, gifts or personality traits would you bring to Mosaic Health?
Have you ever counseled a woman who was considering an abortion? If yes, please explain.
Have you had any traumatic experiences relating to abortion? If yes, please explain.
Please list any media or other material that you have read, viewed, or listened to relating to abortion, pregnancy, or abortion alternatives.
Have you ever known a single, pregnant woman?
Under what circumstances would you consider abortion an alternative for a woman with an unplanned pregnancy?
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Never an option
In cases of rape or incests
In cases where the mother's life in in extreme peril
In cases of extreme psychological distress
Other
How would you rate your knowledge of abortion procedures?
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Excellent
Good
Fair
Poor
How would you rate your knowledge of what the Bible teaches about abortion?
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Excellent
Good
Fair
Poor
Are you currently or have you ever been involved in seeking to adopt a child? If yes, please explain.
EDUCATION
Name of High School
Diploma?
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Yes
No
G.E.D.
Name of College/Vocational School
Type of Degree/Certification
Other training:
EMPLOYMENT HISTORY
Employer (list most recent first)
Address
Phone number
Supervisor's Name
Employment Dates:
Position/Duties:
Employer
Copy of Address
Phone number
Supervisor's Name
Employment Dates:
Position/Duties:
REFERENCES - Please provide 3 personal references to whom you are not related and who you have known for at least 2 years, including your pastor.
First / Last name
Phone number
Years Acquainted:
Relationship:
First / Last name
Phone number
Years Acquainted:
Relationship:
First / Last name
Phone number
Years Acquainted:
Relationship:
I have read and am in full agreement with Mosaic Health's
Core Values
.
I agree
I have read and am in full agreement with Mosaic Health's
Statement of Faith
.
.
I agree
I have read and am in full agreement with Mosaic Health's
Statement of Principle
.
I agree
Additional Documents
Terms of Service
I agree to the
terms of service
.
Verification
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