A registered 501(c)3 nonprofit organization
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Volunteer Application
Volunteer Information
0
Name
*
1
Employer
*
2
Email
*
3
Phone
*
4
Address
*
5
*
City
6
*
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
*
Monday
Tuesday
Wednesday
Thursday
Friday
Morning
Afternoon
Evening
17
Are you available on weekends?
*
Yes
No
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Additional Comments:
*
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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
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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.
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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.
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Submit
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