Volunteer to Help With Events

Name*
Email Address*
Street Address*
City/State/Zip*ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
Phone*
Company/Group
Occupation
Date of Birth:JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember01020304050607080910111213141516171819202122232425262728293031201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900
Do you wish to be recognized as a breast cancer survivor?---yesno
I prefer to be contacted by:---PhoneEmailTextMail
 Yes, I woudl like to receive emails from TBCS. Yes, I woudl like to receive postal mail from TBCS.

*Have you ever been convicted (including entering a plea of guilty or nolo contendere) of any felony crimes within the past 7 years? Do not include convictions that were sealed or expunged pursuant to a court order. (A “yes” is not an automatic bar to volunteer service with The Breast Cancer Society; the circumstances relating to the offense will be considered in relation to the volunteer position for which you are applying.)
---noyes

*If you answered "Yes", please provide the following information: The date, place of the offense and charge.

Have you volunteered in the past for TBCS?---yesno
If so, when?
If you speak a foreign language and are willing to share your skills, please indicate which language(s).
Please indicate if you have experience in the following areas: (You may select multiple areas) Data Entry  Excel and Word  Event Planning  Finance  Fundraising  Grant Writing Health Care Professional  Journalism  Photography  Public Relations  Public Speaking  Teaching
Please list any additional skills that you would be willing to contribute.

How often would you like to volunteer? Weekly  Monthly  Occasionally
Daytime Availability
Evening Availability
Weekend Availability
*I'm interested in helping in the following areas: (You may select multiple areas)  Hope Supply Program AZ Hope Supply Program PA Fundraising Events Breast Cancer Patient Support Groups Other

Name*
Phone*
Relationship to Volunteer*

Volunteer Applicant Statement

(Read Carefully Before Signing)

I certify that I completed this volunteer application and that all the answers to the questions on this volunteer application and any attachments are to the best of my knowledge true and correct and that I have not knowingly withheld any pertinent facts or circumstances all of which are subject to validation. I understand that any misrepresentation, false statement, or omission made by me with respect to the information contained in this volunteer application could disqualify me from consideration as a volunteer, or if selected as volunteer, result in the termination of my volunteer efforts from The Breast Cancer Society, Inc.

If selected as a volunteer, I agree to comply with the rules and regulations of The Breast Cancer Society, Inc. I also understand that smoking is prohibited in all indoor areas of The Breast Cancer Society, Inc.

The Breast Cancer Society, Inc Volunteer Release

I wish to volunteer for The Breast Cancer Society, Inc (TBCS). I understand that my consent to these provisions is given in consideration for being permitted to volunteer for the TBCS. I UNDERSTAND THAT THE NATURE OF VOLUNTEER ACTIVITIES THAT I MAY PERFORM IN MY CAPACITY AS A VOLUNTEER MAY INVOLVE PHYSICAL ACTIVITY, CONTACT WITH UNIDENTIFIED OR UNFAMILIAR PERSONS, OR OTHER POTENTIAL RISK OF BODILY INJURY OR DAMAGE TO PROPERTY AND I HEREBY VOLUNTARILY ASSUME FULL AND COMPLETE RESPONSIBILITY FOR, AND THE RISK OF, ANY INJURY OR ACCIDENT WHICH MAY OCCUR DURING MY VOLUNTEER WORK WITH TBCS. TO THE FULLEST EXTENT OF THE LAW, I, FOR MYSELF, MY NEXT OF KIN, MY HEIRS, ADMINISTRATORS, AND EXECUTORS (COLLECTIVELY, “RELEASORS”), HEREBY RELEASE AND HOLD HARMLESS AND COVENANT NOT TO FILE SUIT AGAINST (I) THE BREAST CANCER SOCIETY, INC. HEADQUARTERS AND THEIR RESPECTIVE DIRECTORS, OFFICERS, VOLUNTEERS, AGENTS AND EMPLOYEES; AND (II) ALL OTHER PERSONS OR ENTITIES ASSOCIATED WITH TBCS HEADQUARTERS (COLLECTIVELY, THE “RELEASEES”) FOR ANY INJURY OR DAMAGES I MIGHT SUFFER IN CONNECTION WITH MY VOLUNTEER WORK WITH TBCS AFFILIATE. THIS RELEASE APPLIES TO ANY AND ALL LOSS, LIABILITY, OR CLAIMS I OR MY RELEASORS MAY HAVE ARISING OUT OF MY VOLUNTEER WORK WITH TBCS AFFILIATE, INCLUDING BUT NOT LIMITED TO, PERSONAL INJURY OR DAMAGE SUFFERED BY ME OR OTHERS, WHETHER SUCH LOSSES, LIABILITIES, OR CLAIMS BE CAUSED BY CONTACT WITH AND/OR THE ACTIONS OF OTHER PERSONS, CONTACT WITH FIXED OR NON-FIXED OBJECTS, NEGLIGENCE OF THE RELEASEES, RISKS NOT KNOWN TO ME OR NOT REASONABLY FORESEEABLE AT THIS TIME, OR OTHERWISE.

I understand that as a volunteer, I may become privy to confidential information. I agree to maintain the confidentiality of any information marked “confidential” as well as any information about each breast cancer patient, family member, business operations, organizational structure, employee information, financial operations, marketing strategy, organization, donor lists and amounts, plans for upcoming events, current or proposed business transactions and sponsorships, and any proprietary information such as computer software and programming and the like that is not otherwise publicly disclosed. I will not use any confidential information in any manner that would be detrimental to TBCS or those they serve and associate with.

At all times during my volunteer work with TBCS, I will conduct myself in such a manner as not to reflect unfavorably on or in any way diminish the reputation of the TBCS and its affiliates.

I give my consent and permission to TBCS and its respective affiliates, successors, licensees, and assigns the irrevocable right to use, for any purpose whatsoever and without compensation, any photographs, videotapes, audiotapes, or other recordings of me that are made during the course of volunteering with TBCS.
This Release shall be construed under the laws of all states in which TBCS conducts services and programs. In the event any provision of this Release is deemed unenforceable by law, (i) TBCS shall have the right to modify such provision to the extent necessary to be deemed enforceable; and (ii) all other provisions of this Release shall remain in full force and effect.

I understand that I have given up substantial rights by signing this Release, and have signed it freely and voluntarily without any inducement, assurance or guarantee being made to me and intend my signature to be a complete and unconditional release of liability to the greatest extent allowed by law.

Volunteer Signature*
*Parent/Guardian Signature
(If volunteer is under age 18)*
Parent/Guardian Contact Information*
Does the volunteer applicant have any physical restrictions?---noyes
If you answered "Yes", please provide more information.
Does the volunteer applicant have any transportation requirements?---noyes
If you answered "Yes", please provide more information.