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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