1. Contact Information

Name:	Title*	First*	Last*
	Mr. Ms. Mrs. Miss Dr.
E-mail*:
Address 1*:
Address 2:
City/State/Zip:	City*	State*	Zip*
		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
Home Phone*:	() -
Work Phone*:	() -
Cell Phone*:	() -
Employer:
Occupation:	Accounting Administrative, Support, and Clerical Advertising Aerospace and Defense Agriculture, Forestry, and Fishing Architecture Arts and Entertainment Aviation and Airlines Banking and Financial Services Clergy Construction and Landscaping Consulting Education and Training Engineering Environment Executive/Management Facilities, Maintenance, and Repair Fire, Law Enforcement, and Security Government Healthcare Homemaking Hotel, Gaming, Leisure, and Travel Human Resources Information Technology (IT) Insurance Legal and Paralegal Manufacturing Marketing Media Military Nonprofit Personal Care and Service Photography Property Management Psychology Publishing Real Estate, Rental, and Leasing Restaurant and Food Services Retail/Wholesale Sales Science and Biotechnology Skilled Work and Trades Social Work Stock Broker/Investment Advisor Student Telecommunications Transportation and Warehousing
Gender*:	Male Female
Date of Birth:	Month	Day	Year
	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908

2. What county do you live in?
Bibb Blount Calhoun Chambers Cherokee Chilton Clay Cleburne Colbert Coosa Cullman DeKalb Etowah Fayette Franklin Greene Hale Jackson Jefferson Lamar Lauderdale Lawrence Limestone Madison Marion Marshall Morgan Perry Pickens Randolph St. Clair Shelby Sumter Talladega Tallapoosa Tuscaloosa Walker Winston
(Please select a county only if you live in Alabama.)

*3. Education:
Please select response High School College Graduate Doctorate

4. What other language(s) do you speak?

*5. Are you a breast cancer survivor?
Yes No

6. What are your hobbies?

7. What do you hope to gain from your Komen volunteer experience?

(Maximum response 250 characters)

8. What tasks do you prefer to do(if any)?
Data Entry
Faxing
Filing
Phone Work
Reception
Mailings

9. In which of the following areas do you have computer skills (if any)?
Typing
Database Management
Excel
Word
Graphic Design (Publisher, InDesign, etc.)

10. In which of the following areas do you have at least 1 year of experience?
Community Outreach
Counseling
Editing
Event Planning
Finance
Fundraising
Grant Writing
Journalism
Management
Photography
Public Relations
Public Speaking
Research
Teaching

11. Do you have any additional/other skills that might be relevant? (i.e. flower arranging, scrapbooking, etc)

(Maximum response 250 characters)

*12. What types of volunteer work are you interested in completing?

(Maximum response 250 characters)

13. Please list any additional affiliations (community groups, alumni associations, etc.)

(Maximum response 250 characters)

14. How did you hear about the Komen Foundation and do you have experience with any of Komen's affiliates? If yes, please list.

(Maximum response 250 characters)

*15. What YEAR (e.g., 2002) did you first volunteer for the Komen North Central Alabama affiliate?
(If this is your first year volunteering, please indicate the current year)
2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991

16. Are you currently volunteering for any other agencies? If yes, please list.

(Maximum response 250 characters)

*17. When are you available to volunteer?
Weekday daytime hours
Weekday evening hours
Weekend hours

*18. How often would you like to volunteer?
Daily
Weekly
Monthly
Race/Special Events

*19. How often may we contact you via e-mail?
Only when events are held in the evenings or on weekends (mainly health fairs & special events) For All volunteer opportunities I prefer to contact Komen when I am available to volunteer

*20. Would you like to receive Komen mailings?
Yes No

21. Comments:

(Maximum response 250 characters)

*22. Emergency Contact Name:
(We will contact this person in case of an emergency while you are volunteering for Komen.)

*23. Relationship of Emergency Contact:

*24. Phone Number of Emergency Contact:
() -

*25. Do you have any health issues that might limit/affect your ability to perform certain types of work?
Yes No

If yes, please specify in the space below health issues.

(Maximum response 250 characters)

Waiver
I hereby verify that to my knowledge the above information is accurate. I recognize that as a Komen volunteer, I am a representative of the North Central Alabama Affiliate of the Susan G. Komen Breast Cancer Foundation and I will follow the guidelines set forth by the said organization.

I wish to volunteer for the North Central Alabama Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc. (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 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 RESPONSIBILITY 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 COVENANT NOT TO FILE SUIT AGAINST THE KOMEN AFFILIATE, THE SUSAN G. KOMEN BREAST CANCER FOUNDATION, 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 of 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.

*27. I agree with the terms of the above waiver. Please note: If you are under 18, a parent/guardian is only allowed to accept this waiver.
Agree

*28. Please type in the word you see in the follwing box: