Volunteer Interested in becoming a volunteer?Fill out the application below! Name * First Name Last Name Birthdate * MM DD YYYY Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Emergency Contact Name * First Name Last Name Relationship * Phone * (###) ### #### Do you give us permission to transport you to the nearest medical facility should you incur serious illness or injury during volunteer hours? * Yes No Availability & Preferences Dates/Times Available Perferred Volunteer Jobs * Select all that apply Chemo Companion (additional training required through the hospital/clinic) Chemo Comfort Bag Stuffing Events Outreach/Community Events Fundraising Support Administrative Support Experience & Skills Do you have any previous volunteer experience? If yes, please describe: Do you have any experience working with individuals undergoing chemotherapy? If yes, please describe: Special skills or qualifications (e.g., languages spoken, certifications, medical background): Additional Information How did you hear about Chemo Companions and our volunteer program? * As a volunteer, you may be required to undergo a background check. Are you willing to complete this process? * Yes No Agreement & Signature Chemo Companions is dedicated to a policy of non-discrimination on any basis including race, color, religion, sex, national origin, sexual orientation, age, disability, status as a Vietnam-era or special disabled veteran, or any other legally protected status. Consistent with the Americans with Disabilities Act, applicants may request accommodations needed to participate in the application process. By clicking "I agree" below, I certify that the above information is true and complete. I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected. I agree that my volunteer status can be terminated, with or without cause, and with or without notice, at any time by Chemo Companions. I agree to abide by the policies and procedures of Chemo Companions and understand that submitting this application does not guarantee placement as a volunteer. * I agree Thank you for submitting your application! A member of our team will be reaching out.
