First Name *
Last Name *
Address *
City *
State *
Zip *
Home Phone Number
Cell Phone Number
Email *
Age *

Marital Status:
Married Divorced Single 

Education Background

Yes No 
Area Of Study
Year Of Graduation
What is extent of your formal education?

Employment & Volunteer Background

Are You Currently Employed?
Yes No 

List Your Employment/Training Background:

Position/Major Responsibility
Dates of service

List Any Previous or Current Volunteer Experience:

Position/Major Responsibility
Dates of service

About Yourself

Please provide the name and phone number of two additional references that you have known at least 5 years. Someone not related to you and not a previous employer .

Reference Name
Phone Number
Reference Name
Phone Number
Why do you want to serve at LivingWell? How do you hope to benefit?
List any special training/skills that could be contributed at your time at LivingWell:
What are your personal strengths?
What are possible areas of weakness?
Please share any other information that you feel would benefit us in knowing about you:


Do you consider yourself a Christian? What is a Christian?

Where do you attend church? We will be contacting your pastor for a reference. Please provide the following information:


Abortion Information

Have you personally had an abortion?
Yes No 
If Yes, have you received any type of post abortion counseling?
Have you ever counseled a woman who is considering abortion?
Yes No 
If yes, please explain:
What specific gifts, talents, or personality traits would you be able to offer a woman dealing with this type of decision?
Have you ever known a single mother?
Yes No 
If yes, please explain:

Under what circumstances would you consider abortion as an option?
 Never an option Known birth defects If a woman feels that is her best option In cases of rape Incest In cases of extreme psychological stress Other

If other, please explain:

How would you rate your knowledge of how abortions are performed/methods used to perform abortions?:
Excellent Good Fair Poor 

Preferences & Availability

I would like to do the following:
 Baby Boutique Counseling Various Clerical and Administrative work Bulk Mailings Host a Baby Bottle Drive Host a Life Party Maintenance Fundraising Events Prayer Team Providing materials by donating or recruiting donations Graphic Art Copywriting Photography Social Media Marketing Walk for Life (WFL) Coach Cleaning

I would like to provide professional services:
 MD, PA, NP Nurse, Ultrasound tech Clergy Attorney

Number of hours available to volunteer each week: (minimum of 4 hours/day required for counseling, 4-8 hours/week recommended)
4-8 9-13 14-17 

Clinic Hours Are: Mon/Tues/Wed/Thurs: 9am-4pm, Fri 9:30am-12:30 pm, and Sat 9:30am-12:30pm (by appointment only)
Please list the time frames you are available to volunteer. We require at least 4 hour time slots per each volunteer visit (ie 12pm-4 pm or 10am-2 pm). If there are no appointments for Saturday, you will not be asked to come in.

Monday Start to Finish
Tuesday Start to Finish
Wednesday Start to Finish
Thursday Start to Finish
Friday Start to Finish
Saturday Start to Finish
(by appointment only)