Tidewater Affiliate Volunteer Sign-Up

  Please complete the following information

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Name:

 

 

 

 

       

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City/State/ZIP:

 

    

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Date of Birth:

 

 


 


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Question - Required - Volunteer support is needed for the following areas. Please mark your top 3 choices.
Please make between 1 and 3 selections from the choices below.

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Question - Required - Do you have expertise or experience in these areas?

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Question - Required - Please indicate your availability. Check all that apply:

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Question - Required - Please indicate the amount of time you are willing to volunteer at this time (check all that apply)

 

Volunteer Release (must be signed in order to participate in Komen events)

I wish to volunteer for the Susan G. KomenŽ Tidewater . I understand that the nature of volunteer activities that may be performed for the Komen Affiliate and during Komen events may involve physical activity, contact with unidentified and/or unfamiliar persons, or other potential risk of personal injury or accident. Knowing this and in consideration of being allowed to volunteer, I hereby assume full and complete responsibility for any 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 the Komen Affiliate, Susan G. Komen® , Inc. (the “Foundation”) 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. I understand that as a volunteer, I may become privy to confidential information about the Komen Affiliate or the Foundation. I agree to maintain the confidentiality of any information marked “Confidential” as well as any information about the Komen Affiliate’s or the Foundation’s internal procedures, business operations, personnel information and the like that is not otherwise publicly disclosed by the Komen Affiliate or the Foundation. I will not use any confidential information in any manner that would be detrimental to the Komen Affiliate or the Foundation, and I will avoid any actions that might impair the reputation of the Komen Affiliate or the Foundation.

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Question - Required - Date:




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