Volunteer

Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

First Name

Last Name

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

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

Photography (you must have your own camera to use)

As a volunteer, you may be required to undergo a background check. Are you willing to complete this process? *

Yes

No

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