• Facebook
  • Twitter
  • YouTube
Toggle Menu

Volunteer

 

Volunteer Placement Survey

 
Question - Not Required - Date




  Contact Information:

*

Name:

 

 

   

*

*

*

City/State/ZIP:

 

    

*

 

If you respond and have not already registered, you will receive periodic updates and communications from Susan G. Komen®.


*
Question - Required - Date of Birth:




*


   


   


*


*


 

*


   


 
Question - Not Required - Please indicate if you have more than one year of experience in the following areas: (You may select multiple areas)

   


 

 


   


 
Question - Not Required - How often would you like to volunteer?



 


 


 


 
Question - Not Required - I'm interested in a:


 
Question - Not Required - Please choose the volunteer areas that you are interested in getting involved in below:


  Komen Volunteer Release
Emergency Contact:
   


   


  I wish to volunteer for Susan G. Komen, Charlotte Affiliate. 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 or unfamiliar persons, or other potential risk of bodily injury or damage to property. Knowing this, I hereby assume full and complete responsibility for any personal injury and/or property damage that I may sustain or cause during my participation as a volunteer. In addition, I hereby release, hold harmless & covenant not to file suit against the Komen Affiliate, Susan G. Komen, Inc. and 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 Susan G. Komen. I agree to maintain the confidentiality of any information marked “confidential” as well as any information about the Komen Affiliate’s or Susan G. Komen’s internal procedures, business operations, personnel information and the like that is not otherwise publicly disclosed by the Komen Affiliate or Susan G. Komen. I will not use any confidential information in any manner that would be detrimental to the Komen Affiliate or Susan G. Komen, and I will avoid any actions that might impair the reputation of the Komen Affiliate or Susan G. Komen.
*  


   Please leave this field empty