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Join Circle of Promise

Komen Advocacy Alliance

Volunteer

Our volunteers come in all shapes, colors and sizes, but their hearts are pink and their caring has no limits. Are you a leader, a thinker or a doer? Use your talents in our promise to save lives and end breast cancer forever! We need you now more than ever. Volunteers provide countless hours contributing their skills to further the Susan G. Komen for the Cure® promise. We will work with your availability. Every minute you spend helping gives another minute of hope to those affected by breast cancer.

If you are interested in volunteering with the San Antonio Affiliate of Susan G. Komen for the Cure, please complete the following form.

**Please note: This form is for Affiliate volunteers only. If you are interested in being a Komen Race for the Cure volunteer, the form will be up at the end of February. Thank you!

We look forward to working with you!

*1.

Question - Required - Date:

Month

Day

Year

*2.

Question - Required - Title:

*3.

Question - Required - Full Name:

*4.

Question - Required - Address:

(Maximum response 255 chars, approx. 5 rows of text)

*5.

Question - Required - Email:

(Maximum response 255 chars, approx. 5 rows of text)

*6.

Question - Required - Day Phone:

Question - Not Required - Cell Phone:

*8.

Question - Required - Are you 18 years or older?

Question - Not Required - If not, please list name and number of parent/guardian:

(Maximum response 255 chars, approx. 5 rows of text)

10.

Question - Not Required - Employer:

11.

Question - Not Required - Position:

*12.

Question - Required - Have you ever been convicted of any type of offense?

*13.

Question - Required - Have you been charged with any crime involving a child?

14.

Question - Not Required - If yes to either, please explain:

(Maximum response 255 chars, approx. 5 rows of text)

*15.

Question - Required - Have you volunteered with Komen in the past?

16.

Question - Not Required - If so: when, where and to what capacity?

(Maximum response 255 chars, approx. 5 rows of text)

17.

Question - Not Required - How did you hear about us?

*18.

Question - Required - I am interested in the following:
Please make between 1 and 9 selections from the choices below.

	Co-Survivor Mentor
	Delivering Gift Baskets
	Office Administration
	Public Relations
	Race for the Cure
	Speaking Events
	Special Events
	Survivor Mentor
	Training

*19.

Question - Required - I am available:
Please make between 1 and 3 selections from the choices below.

	Days
	Evenings
	Weekends

*20.

Question - Required - Would you like to be recognized as a breast cancer survivor?

*21.

Question - Required - Do you speak Spanish?

*22.

Question - Required - Emergency contact name:

*23.

Question - Required - Emergency contact number:

24.

Question - Not Required - Do you have any health issues we should be aware of?

*25.

Question - Required - I have read and fully understand the following statement: I wish to volunteer for the San Antonio Affiliate of Susan G. Komen for the Cure. 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 and/or unfamiliar persons, or other potential risk of bodily injury or damage to property. Knowing this and in consideration of being allowed to volunteer, I HEREBY ASSUME FULL AND COMPLETE RESPONSIBILITY FOR ANY PERSONAL INJURY AND/OR PROPERTY DAMAGE THAT I SUSTAIN OR CAUSE DURING MY PARTICIPATION AS A VOLUNTEER. IN ADDITION, I HEREBY RELEASE, HOLD HARMLESS AND COVENANT NOT TO FILE SUIT AGAINST SUSAN G. KOMEN FOR THE CURE OR ITS SAN ANTONIO AFFILIATE AND ANY OF THEIR EMPLOYEES, VOLUNTEERS, PARTNERS, AGENTS, SPONSORS, BOARD MEMBERS AND SUCCESSORS FROM ANY AND ALL LOSS, LIABILITY OR CLAIMS I MAY HAVE ARISING OUT OF MY SERVICE AS A VOLUNTEER.

*26.

Question - Required - I have read and fully understand the following statement: I understand that as a volunteer, I may become privy to confidential information about Susan G. Komen for the Cure or its San Antonio Affiliate. I agree to maintain the confidentiality of any information marked "confidential" as well as any information about the Susan G. Komen for the Cure or its San Antonio Affiliate's internal procedures, business operations, personnel information and the like that is not otherwise publicly disclosed by Susan G. Komen for the Cure or its San Antonio Affiliate. I will not use any confidential information in any manner that would be detrimental to Susan G. Komen for the Cure or its San Antonio Affiliate, and I will avoid any actions that might impair the reputation of Susan G. Komen for the Cure or its San Antonio Affiliate.

San Antonio Affiliate of Susan G. Komen for the Cure®
P. O. Box 6678 San Antonio, Texas 78209 · Phone: 210-222-9009 · Fax: 210-222-9766 · Email: info@sakomen.net

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