Mens coaching | Choices of WNC

First name

Last name

Phone Number

Email

Birthday

Month

Day

Year

Street Address

City

State

Zip

Emergency Contact Name

Emergency Contact Phone Number

Church Affiliation

Are you an active church member?

Yes

No

Occupation

What do you know about our work/mission?

Special skills/gifts you may want to mention (such as fluent in other language or background and experience).

How many hours are you able to commit to?

Please give a summary of your Christian beliefs and how you were led into pro-life ministry.

Please list any pro-life activities, participation in other ministries and any organizations you belong to:

Why do you want to volunteer

Under what circumstances do you feel abortion may be justified?

We do not offer, recommend or refer for abortions, abortifacients or contraceptives. We are committed to offering accurate information about related risks and procedures. Are you able to agree with these standards?

Yes

No

Do you know of anyone that has had an abortion?

Yes

No

Are you willing to sign a Statement of Faith/Code of Christian Conduct?

Yes

No

Please list 3 references.

Reference 1 First and Last Name

Reference 1 Phone Number

Reference 2 First and Last Name

Reference 2 Phone Number

Reference 3 First and Last Name

Reference 3 Phone Number

Insurance Waiver

I carry adequate medical insurance and I accept full responsibility for medical costs associated with an injury while volunteering at the center.

I do not carry medical insurance and I accept full responsibility for medical costs associated with an injury while volunteering at the center.

Name of Insurance Carrier (if none type "none".

Signature

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