A registered 501(c)3 nonprofit organization
Volunteer Application
  • Volunteer Information
    0
  • Name*
    1
  • Employer*
    2
  • Email*
    3
  • Phone*
    4
  • Address*
    5
  • *City
    6
  • *State
    7
  • *Zip Code
    8
  • Are you a cancer survivor?*
    Yes
    No
    9
  • If yes, what type of cancer?*
    10
  • Emergency Contact
    11
  • Name*
    12
  • Phone*
    13
  • Name*
    14
  • Phone*
    15
  • Availability
    16
  • Availability*MondayTuesdayWednesdayThursdayFriday
    Morning
    Afternoon
    Evening
    17
  • Are you available on weekends?*
    Yes
    No
    18
  • Additional Comments:*
    19
  • What areas interest you?*Choose all that apply
    Transport/Appointment Buddy
    Event Planning & Promoting
    Grant Writing
    Information Technology
    Guest Speaker/Education
    Marketing & Community Relations
    Fundraising
    Office Assistance
    Advocacy/Legislation
    Budget/Finance
    20
  • By submitting this application, I agree that CoCC shall not be liable for any injury that I may incur while participating in a sponsored activity or project. I agree to its unrestricted use and publication in any media of photograph, recording, interview, videotape, or other recording of me in connection with any activities in which I may participate with CoCC.
    21
  • Privacy Statement: Personal Identifiable and Health Care Information will be treated and protected as privileged and confidential health information, which is protected by state and federal statues, rules and regulations and will not be shared outside of the organization and medical treatment facility. Any further disclosure of information is prohibited without the specific prior written consent of the person to whom the information pertains, or as otherwise permitted by law.
    22
  • 23