Connect with Miriam's Heart!
This form is used for all families, individuals and volunteers who assist Miriam's Heart
Name (First & Last)
Indicate your first and last name
Your answer
indicate your mailing address including City, State and Zip
Your answer
Cell Phone
Your answer
Email Address
Your answer
Adoptive & Foster Family?
Indicate if you are an adoptive or foster family?
Where did you adopt from?
Indicate where your child was adopted from?
Your answer
Interested in adoption or foster care?
Indicate if you are interested in adoption or becoming a foster parent
Have you ever been convicted or plead guilty to any crime involving or against a minor?
Are there any criminal charged pending against you regarding any crime(s) involving or against a minor?
Have you ever been refused participation in any other youth programs?
Church Affiliation
Indicate the name of the church you are affiliated with
Your answer
Reference #1
Indicate 1 personal reference & phone number
Your answer
Reference #2
Indicate 1 personal reference & phone number
Your answer
Background Waiver
As a condition of volunteering, I give permission for Miriam's Heart to conduct background check(s) on me now and for as long as I continue to be active with the organization, which may include a review of sex offender registries, child abuse and criminal history records. I understand that if appointed, my position is conditional upon there being no inappropriate information on my background. I hereby release and hold harmless from liability Miriam's Heart, Inc and Zarephath Christian Church, the officers, employees, volunteers, and any other person or organization that may provide such information. I understand that Miriam's Heart, Inc. reserves the right not to accept my application to volunteer and that at any time I may be asked to resign my position.
Waiver and Release of Liability
I release and waive liability in favor of Miriam's Heart, Inc and Zarephath Christian Church, both non profit organizations in New Jersey, their officers, directors, employees, volunteers and agents. I desire to work as a volunteer for Miriam's Heart and engage in the activities related to being a volunteer and hereby freely, voluntarily and without duress release Miriam's Heart, Inc. I hereby release and forever discharge and hold harmless Miriam's Heart, its successors and assigns from any and all liability, claims and demands whatsoever. I understand that this Release discharges Miriam's Heart and Zarephath Christian Church from any liability which may come as a result of any bodily injury, personal injury, illness, death or property damage that may result of my volunteering regardless of negligence of Miriam's Heart and/or Zarephath Christian Church. I understand that Miriam's Heart does not assume any responsibility to provide financial assistance of any kind in the event of injury or illness.
Assumption of the Risk
I understand that the activities included in my volunteering and participating in Miriam's Heart events may be hazardous and I understand and assume this risk.
Photography & Media Release
I grant and convey to Miriam's Heart all right, title, and interest in any and all photographic images, video, and audio recordings made by Miriam's Heart during my volunteer activities. I understand that many of the events attended by and hosted by Miriam's Heart are in some way photographed, filmed and recorded; and I consent to these recordings. This includes, but is not limited to any royalties, proceeds, or other benefits derived from such photographs and recordings. I grant permission for these images to be used on the social media accounts of Miriam's Heart, their directors, officers, employees, volunteers and agents.
Professional Skills & Experience
Indicate any professional skills you might have to assist Miriam's Heart
do you have any questions or comments?
Your answer
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