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printable form

100 Stars Volunteer Registration Form
Print Name: _____________________________________ Date of Birth ____________
Address: ________________________________________________________________
City: ___________________________ State: _______________ Zip: _______________
Telephone Numbers: ______________________________________________________
E-Mail Address: __________________________________________________________
Employer / Occupation / Profession: __________________________________________
Hobbies & Interests: ______________________________________________________
Listed below are various activities in which you may volunteer to serve in one or more youth programs during the year. Please select the activities that you are most interested in and/or best fit your schedule.
( ) Mentor for youth
( ) Age 7-12 ( ) 13-17 ( ) 18-21 ( ) Young Adults
( ) Male ( ) Female ( ) Both
( ) Tutor ( ) Grade _____ ( ) Subject(s) ____________________________________
( ) Job Shadowing ( ) Workplace Tours
( ) Life Skills Seminar ( ) Field Trip Chaperone
( ) Parent Education Seminar ( ) Speakers Bureau
( ) Telephone Calls ( ) Mailings
( ) General Office Work ( ) Distribute Literature
( ) Fundraising Events ( ) Host/Hostess
( ) Research ( ) Provide Food & Beverages
( ) Volunteer Coordinator ( ) Program Facilitator
( ) Professional Services ( ) Provide Resources: _________________
( ) Other: _______________________________________________________________
Signature: __________________________________________Date: ________________
Please complete this form and return it to: 100 Black Men of Greater Cleveland, Inc. at 4415 Euclid Avenue, Suite 331, Cleveland, Ohio 44103
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