2019 Volunteer Application and Waiver

1. Contact Information

If you have previously registered, please to prepopulate your information.

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Name:

 

 

   

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5 to 60 characters

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5 to 20 characters

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Question - Required - Date of birth:




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*4.
Question - Required - Availability:
Please make between 1 and 4 selections from the choices below.

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7.
Question - Not Required - Are you a student?



 

From the areas listed below, choose the volunteer areas that interest you.

8.
Question - Not Required - Survivor Speaking Engagements (Telling your story, speaking in front of groups large and small.)


9.
Question - Not Required - More Than Pink Walk® Volunteer (Must be available on Walk Day. May require training)


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Question - Not Required - Special Events Volunteer (Includes assisting with Komen events and fundraisers. Availability on weekends and evenings required.)


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Question - Not Required - Educational Events Volunteer (Includes assisting with health fairs and educational events. Must be comfortable speaking in front of groups. Availability on weekdays, evenings and weekends required. Training will be provided.)


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Question - Not Required - Office Volunteer: (To assist in the office, Monday-Friday, during office hours.)


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Question - Not Required - Public Policy Volunteer (Must be knowledgeable in advocacy/public policy. Must be conformable speaking in front of groups.)


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Question - Required - Are you able to lift boxes 10lbs or more?


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Question - Required - Can you handle setting up a table at an event?


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Question - Required - When staffing an event you will be required to to pick up the supplies either from the office or a central location before the event, and then return them after the event. Are you able to do this?


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Question - Required - Are you willing to travel? Choose all that apply.
Please make between 1 and 6 selections from the choices below.

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Question - Required - Are you bilingual? Choose all that apply.
Please make between 1 and 4 selections from the choices below.

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Information to Volunteer Applicants  (read carefully before signing)

 

You may be asked to sign an authorization for the Susan G. Komen Miami/ Ft. Lauderdale to fully investigate your suitability for volunteering (depending on the position and responsibilities) by obtaining information from your previous employers and/or other knowledgeable persons as to their firsthand experiences with you, and also, when deemed necessary, by obtaining reports from credit bureaus, credit agencies, or other consumer reporting agencies.  Under some circumstances, certain of such reports may be “consumer reports” or "investigative consumer reports" as to which, under the Fair Credit Reporting Act, you are entitled, upon your request in writing, to receive a complete and accurate disclosure of the nature and scope of the investigation requested by the Susan G. Komen Miami/ Ft. Lauderdale

 

Volunteer Applicant Statement  (read carefully before signing)

 

I certify that I completed this volunteer application and that all the answers to the questions on this volunteer application and any attachments are to the best of my knowledge true and correct and that I have not knowingly withheld any pertinent facts or circumstances all of which are subject to validation.  I understand that any misrepresentation, false statement, or omission made by me with respect to the information contained in this volunteer application could disqualify me from consideration as a volunteer, or if selected as volunteer, result in the termination of my volunteer efforts from the Susan G. Komen Miami/Ft. Lauderdale Affiliate. I certify I am at least 18 years old. I understand I have given up substantial rights by accepting this Release and have signed it freely and voluntarily without any inducement, assurance or guarantee. I intend my acceptance to be a complete and unconditional release of liability to the greatest extent allowed by law. If selected as a volunteer, I agree to comply with the rules and regulations of Susan G. Komen Miami/Ft. Lauderdale Affiliate. I also understand that smoking is prohibited in all indoor areas of the Susan G. Komen Miami/Ft. Lauderdale Affiliate.

 

Komen Volunteer Release

 

I wish to volunteer for the Miami/Ft. Lauderdale Affiliate of Susan G. Komen Breast Cancer Foundation d/b/a Susan G. Komen Miami/Ft. Lauderdale Affiliate (“Komen Affiliate”).  I understand that my consent to these provisions is given in consideration for being permitted to volunteer for the Komen 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 and I hereby voluntarily assume full and complete responsibility for, and the risk of, any injury or accident which may occur during my VOLUNTEER WORK WITH THE KOMEN AFFILIATE. TO THE FULLEST EXTENT OF THE LAW, I, FOR MYSELF, MY NEXT OF KIN, MY HEIRS, ADMINISTRATORS, AND EXECUTORS (COLLECTIVELY, “RELEASORS”), HEREBY RELEASE AND HOLD HARMLESS AND COVENANT NOT TO FILE SUIT AGAINST (I) THE KOMEN AFFILIATE, THE SUSAN G. KOMEN BREAST CANCER FOUNDATION, INC. D/B/A SUSAN G. KOMEN FOR THE CURE (“KOMEN HEADQUARTERS”), AND ALL OTHER AFFILIATES OF KOMEN HEADQUARTERS, INCLUDING THE AFFILIATE CONDUCTING EVENT (“AFFILIATE”), AND THEIR RESPECTIVE DIRECTORS, OFFICERS, VOLUNTEERS, AGENTS AND EMPLOYEES; AND (II) ALL OTHER PERSONS OR ENTITIES ASSOCIATED WITH THE KOMEN AFFILIATE OR KOMEN HEADQUARTERS (COLLECTIVELY, THE “RELEASEES”) FOR ANY INJURY OR DAMAGES I MIGHT SUFFER IN CONNECTION WITH MY VOLUNTEER WORK WITH THE KOMEN AFFILIATE.  THIS RELEASE APPLIES TO ANY AND ALL LOSS, LIABILITY, OR CLAIMS I OR MY RELEASORS MAY HAVE ARISING OUT OF MY VOLUNTEER WORK WITH THE KOMEN AFFILIATE, INCLUDING BUT NOT LIMITED TO, PERSONAL INJURY OR DAMAGE SUFFERED BY ME OR OTHERS, WHETHER SUCH LOSSES, LIABILITIES, OR CLAIMS BE CAUSED BY CONTACT WITH AND/OR THE ACTIONS OF OTHER PERSONS, CONTACT WITH FIXED OR NON-FIXED OBJECTS, NEGLIGENCE OF THE RELEASEES, RISKS NOT KNOWN TO ME OR NOT REASONABLY FORESEEABLE AT THIS TIME, FROM ANY AND ALL CLAIMS, LIABILITIES, ACTIONS, DEMANDS, EXPENSES AND ATTORNEYS’ FEES ARISING OUT OF MY VOLUNTEER ACTIVITIES (COLLECTIVELY, “ACTIVITIES”), OR OTHERWISE.

 

I understand that as a volunteer, I may become privy to confidential information about a Releasee. I agree to maintain the confidentiality of any information marked “confidential” as well as any information about each Releasee’s business operations, organizational structure, employee information, financial operations, marketing strategy, organization, donor lists and amounts, plans for upcoming events, current or proposed business transactions and sponsorships, and any proprietary information such as computer software and programming and the like that is not otherwise publicly disclosed.  I will not use any confidential information in any manner that would be detrimental to a Releasee.

 

At all times during my volunteer work with the Komen Affiliate, I will conduct myself in such a manner as not to reflect unfavorably on or in any way diminish the reputation of the Komen Affiliate, Komen Headquarters and its affiliates. 

 

I understand that I have given up substantial rights by signing this Release, and have signed it freely and voluntarily without any inducement, assurance or guarantee being made to me and intend my signature to be a complete and unconditional release of liability to the greatest extent allowed by law.

 

I am medically/physically able to volunteer and take full responsibility for consulting a physician. I consent to emergency medical care/transportation if injured, as medical professionals deem appropriate. This Release extends to any liability arising out of or in any way connected to medical care/transportation provided, including negligent emergency rescue operations.

I will obey all laws, rules and safety procedures relating to my activities. I will exhibit appropriate behavior at all times and conduct myself in a manner as not to endanger the safety of or negatively affect Event or any person/property.

 

I give Releasees the irrevocable, perpetual and worldwide right to use, copy, publicly perform/display, distribute, modify, translate, and create derivative works of, for any purpose and without compensation, any personal statements, photos, videos, audio, and other recordings of me made during my activities and any original material I create in connection with my activities. Without limiting the foregoing, I agree all personal information I provide in connection with my activities may be used according to the privacy policy referenced below.

 

This Release will be construed under the laws of the state where Event is held. If any provision of this Release is deemed unenforceable by law, Affiliate may modify such provision to the extent needed to be deemed enforceable and all other provisions will remain in full force and effect.

 

If Event is held in CA, the following applies: This Release extends to claims and facts unknown and unsuspected to exist at the time of executing this Release.  All rights under Section 1542 of the California Civil Code are hereby expressly waived with respect to any of the claims, injuries, or damages described in this Release.  Section 1542 of the California Civil Code reads as follows: A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF KNOWN BY HIM MUST HAVE MATERIALLY AFFECTED HIS SETTLEMENT WITH THE DEBTOR.

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