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Date* January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901
Name*
Volunteer Position Sought*
Please list all areas you are interested in serving.
, AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Phone*( ) -
Email*
Have you ever been convicted of a crime other than a minor traffic offense (even while in the military)? * Yes No
If yes, please explain.
EDUCATION
Name of High School
Number of Years Completed 1 2 3 4
Diploma Yes No G.E.D
Name of College and/or Vocational School
Number of Years Completed 1 2 3 4 5 6 7
Degree/s Earned and Date
Describe other training or degrees:
EMPLOYMENT HISTORY
List most recent employment first.
Employer
Phone( ) -
Supervisor Name
Date of employment: From - MM/YY To - MM/YY
Position/Duties
Date of Employment: From - MM/YY To - MM/YY
ADDITIONAL INFORMATION
What is your reason for seeking to volunteer here?*
Do you consider yourself a Christian? If yes, how long have you been a Christian?*
As a Christian, what is the basis of your salvation?*
Current Church Name & Denomination*
Current Pastor & Church Phone Number*
Please list any areas in which you have served at your church.*
Mosaic Health is a pro-life, Christian ministry. 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 this ministry?*
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.*
Have you ever known a pregnant, single woman?*
Never an option
In cases of rape or incest
In cases where the mother's life was in extreme peril
In cases of extreme psychological distress
Other
Select all that apply.
Please list any books, films or other material that you have read or viewed that relate to abortion, pregnancy or alternatives to abortion.*
Excellent
Good
Fair
Poor
Are you currently or have you ever been involved in seeking to adopt a child? If yes, please explain.*
REFERENCES
Please provide three personal references who are not related to you and who have known you for at least two years, including your pastor.
Years Acquainted*
Relationship*
I certify that the facts set forth in this volunteer application are true and complete to the best of my knowledge, and I authorize the pregnancy center to verify their accuracy and to obtain reference information concerning my character and capabilities. I release the pregnancy center and any person or entity providing such reference information from any and all liability relating to the provision of such information or relating to any decisions made based upon such information. I give permission to the center to conduct a criminal background check to the extent that my volunteer duties may involve direct interactions with minors. If I become a volunteer at the pregnancy center, I agree to fully adhere to its policies and rules, including those rules relating to maintaining client confidentiality. I recognize that, as a volunteer, I will serve in a different role than the employees of the pregnancy center and I am not seeking, nor expecting to receive, any compensation or other benefits in return for any volunteer services which I may provide for this ministry.
MOSAIC HEALTH STATEMENTS
I further certify that I have read and that I am in full agreement with Mosaic Health's Core Values
Our core values are a set of unchanging beliefs or principles that guide and govern the decisions within Mosaic Health. Treasuring Life – All human life absolutely valued Deuteronomy 30:19 – “I call heaven and earth as witnesses today against you, that I have set before you life and death, blessing and cursing; therefore choose life that both you and your descendants may live;” Genesis 1:27 - “So God created man in his own image; in the image of God he created him; male and female he created them.” Demonstrated by…Defending, protecting, and honoring all human life from conception forward Representing Christ – Perfect love personified Colossians 1:10 – “That you may walk worthy of the Lord, fully pleasing Him, being fruitful in every good work and increasing in the knowledge of God;” 1 Peter 4:11 – “If anyone speaks, he should do it as one speaking the very words of God. If anyone serves, he should do it with the strength God provides, so that in all things God may be praised through Jesus Christ. To him be the glory and the power for ever and ever. Amen.” Demonstrated by…Bringing honor and glory to God in the way we serve and care for our clients Upholding Integrity – Truth lived by example Psalm 78:72 – “So he (David) shepherded them according to the integrity of his heart, and guided them by the skillfulness of his hands.” Titus 2:7-8 – “In everything set them an example by doing what is good. In your teaching show integrity, seriousness and soundness of speech that cannot be condemned, so that those who oppose you may be ashamed because they have nothing bad to say about us.” Demonstrated by…Living our lives in accordance with God’s truth so that others may see and know Him Transforming People – Lives changed by the Gospel Isaiah 61:1 – “The Spirit of the Lord God is upon Me, Because the Lord has anointed Me to preach good tidings to the poor; He has sent Me to heal the brokenhearted, to proclaim liberty to the captives, and the opening of the prison to those who are bound;” John 17:3 – “Now this is eternal life: that they may know you, the only true God, and Jesus Christ, whom you have sent.” Demonstrated by…Embracing the power, love, and forgiveness of Christ in our lives and sharing that salvation with others Having Faith – Mountains moved by faith Hebrews 11:6 – “But without faith it is impossible to please Him, for he who comes to God must believe that He is, and that He is a rewarder of those who diligently seek Him.” Mark 9:23 – “Jesus said to him, ‘If you can believe, all things are possible to him who believes.” Demonstrated by…Depending on God for things unseen and believing in His power to provide
I further certify that I have read and that I am in full agreement with Mosaic Health Statement of Faith
1. We believe the Bible to be the inspired, the only infallible, authoritative Word of God. 2. We believe that there is one God, eternally existent in three persons: Father, Son and Holy Spirit. 3. We believe in the deity of our Lord Jesus Christ, in His virgin birth, in His sinless life, in His miracles, in His vicarious and atoning death through His shed blood, in His bodily resurrection, in His ascension to the right hand of the Father, and in His personal return in power and glory. 4. We believe that for the salvation of lost and sinful man, regeneration by the Holy Spirit is absolutely essential, and that this salvation is received through justification by faith in Jesus Christ as Savior and Lord. 5. We believe in the present ministry of the Holy Spirit by whose indwelling the Christian is enabled to live a godly life and to perform good works. 6. We believe in the resurrection of both the saved and the lost; they that are saved unto the resurrection of life and they that are lost unto the resurrection of damnation. 7. We believe in the spiritual unity of believers in our Lord Jesus Christ. Adapted from the National Association of Evangelical’s statement of faith
I further certify that I have read and that I am in full agreement with Mosaic Health Statement of Principle.
1. Mosaic Health is an outreach ministry of Jesus Christ through His church. Therefore, embodied in its volunteers, it is committed to presenting our Lord's gospel to women with crisis pregnancies—both in word and deed. Commensurate with this purpose, those who labor as CPC board members, directors, and volunteers are expected to know Christ as their Savior and Lord. 2. Mosaic Health is committed to providing its patients with accurate and complete information about prenatal development and abortion. 3. Mosaic Health is committed to integrity in dealing with patients, earning their trust, providing promised information and services, and eschewing any deception in its corporate advertising or individual conversation. 4. Mosaic Health is committed to assisting women in carrying to term by providing emotional support and practical assistance. Through the provision of God’s people and the community, women may face the future with hope and plan constructively for themselves and their babies. 5. Mosaic Health does not discriminate in providing services because of its patients' race, creed, color, national origin, age, or marital status. 6. Mosaic Health does not recommend, provide, or refer for abortion or abortifacients. 7. Mosaic Health offers assistance free of charge at all times. 8. Mosaic Health is committed to creating awareness within the local community of the needs of pregnant women and of the fact that abortion only compounds human needs rather than resolving them. 9. Mosaic Health does not recommend, provide, or refer single women for contraceptives. (Married women seeking contraceptive information should be urged to seek counsel from their pastor and physician, along with their husbands.) 10. Mosaic Health recognizes the validity of adoption as one alternative to abortion but is not biased toward adoption when compared to the other life-saving alternatives. Mosaic Health is independent of adoption agencies, relating to them in the same manner as to other helpful referral sources. We receive no payments from these agencies, do not enter into contractual relationships with them, and do not share combined office space. Adoption agencies are not established under the auspices of centers. Mosaic Health neither initiates nor facilitates independent adoptions, though they may refer for independent adoptions in states where it is legal.
