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	CONTACT US Susan G. Komen For The Cure Southern Arizona 4574 E. Broadway, Tucson, AZ 85711 P: (520) 319-0155

Volunteers

Volunteer Interest Form

To help in the office, for special events, or for the Race, please complete this form and click the "submit your interest form" button.

If you would like to volunteer on the Race for the Cure committee, or would like to learn more about the positions available on the committee, review the Race for the Cure volunteer positions PDF.

Personal Contact

First Name
Last Name
Current Address
City
State	Zip
Home Phone	Cell Phone
E-Mail

Emergency Contact

First Name
Last Name
Home Phone	Cell Phone
E-Mail
Relationship
Preferred Hospital
Primary Physician
Physician Telephone

Demographics

Date of Birth (MM/DD/YY)
T-shirt Size
Are you a:	Survior Co-Survior
Hobbies
Please List Foreign Language(s) Spoken
Please List Foreign Language(s) Written
Please List Computer Skills
Please List Any Health Issues Which May Impact Your Volunteer Position:

Education

Are you currently a student? Yes No
Studies

Employment History

Are you currently employed? Yes No
Company
Position
Dates
Company
Position
Dates
Company
Position
Dates

Volunteer History

Please list organizations and capacity in which you have volunteered
Organization
Capacity
Dates
Organization
Capacity
Dates
Organization
Capacity
Dates

Volunteer Basics

Please check all volunteer areas in which you have an interest. Please check all that apply.

I am ONLY interested in volunteering for Race for the Cure

Administrative Advocacy Development Education Grants Panelist

Health Fairs Office Race Speaker's Bureau Special Events Other

Other
Please list any specialized skills
Please describe what customer service means to you:

Availability

Please check the shift(s) and day(s) you would be available to volunteer:

Frequency: Occasionally Monthly Bi-weekly Weekly Other

Day/Time	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
AM
PM

Susan G. Komen Southern Arizona Volunteer Release Form

I wish to volunteer for Suan G. Komen for the Cure Southern Arizona. I understand that the nature of volunteer activities that I may perform in my capacity as a volunteer many 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 responsiblity 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 convenant not to file suit against the Komen Affiliate, Susan G. Komen for the Cure® and any of their employees, volunteers, partners, agents, sponsors, board members and successors from any and all loss, liability or claim's 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 Komen. I agree to maintain the confidentiality of any information marked "confidential" as well as any information about the Komen Affiliate's or Komen's internal procedures, business operations, personnel information and the like that is not otherwise publicly disclosed by the Komen Affiliate or Komen. I will not use any confidential information in any manner that would be detrimental to the Komen Affiliate or Komen, and I will avoid any actions that might impair the reputation of the Komen Affiliate or Komen.

Please DO NOT place me in a job which requires (please check all that apply):

Heavy lifting (50 pounds or more)
Light lifting (5-10 pounds)
Standing for 30 or more minutes
Withstanding high temperatures (80+ degrees)
Being in the sun for more than 10 minutes

Dealing with numbers
Alphabetizing
Excessive walking
Handling money
A lot of mental pressure

Printed name

If under 18 years of age, this Waiver & Release must be accepted by a parent or legal guardian.

Signature Date
Signature Date