VOLUNTEER APPLICATION. Name * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone (###) ### #### Cell Phone * (###) ### #### County you live in within your state * Birth Date * MM DD YYYY Please check preferred method of contact: Email Home Phone Cell Phone Race/Ethnicity We use this information when applying for grants African American American Indian Asian Caucasian/White Hispanic/Latino Other How did you hear about Cancer Support Services? * Do you have a truck? ✓ Yes No Are you Volunteering as a part of a group? ✓ Yes No If yes, please list group name Have you or a loved one experienced cancer? Please check all that apply: Self Relative Friend Caregiver Co-worker If you have personally experienced cancer, please select all that apply: Breast Cervical Colon/Rectal Leukemia/Lymphoma Lung Ovarian Other If you selected other, please specify Have you received a Lydia tote? Yes No Employer Name: Type of Work: Place Where You Attend Worship: *if you have one How would you like to volunteer for Cancer Support Services? * Please check all that apply Work with Fabric: Cut fabric at the agency Sew customized quilts for children from your sewing machine anywhere in the nation. Note: parents are asked what their young cancer fighter's favorite color, characters, superheroes are before a quilt is sewn. Sew Twin Size Quilts from anywhere in the nation. Note: quilts are given to men and women cancer fighters the first day of their housing near cancer treatment. Prayer Team: Receive weekly prayer report by e-mail anywhere nationwide to pray for recipients Prayer Team: Pray for those served during weekly prayer via Zoom (9:30-10:00am, Thursdays) Support Team: Write encouraging notes to cancer fighters from your home anywhere in the nation Support Team: Make encouraging phone calls to cancer fighters (from the agency) Support Team: Provide fresh fruit for patients staying in the Lodging Area to be near cancer treatment. Support Team: Distribution of totes to individuals/doctors’ offices /hospitals in the agency’s local area Support Team: Provide a meal from a local restaurant for cancer fighters one evening. Note: 15-20 cancer fighters. Support Team: Volunteer in the Lodging Area maintain a helping presence where guests feel safe in lodging area. Requires criminal background check. (Much needed/ lodging remains open) Support Team: Assist with cleaning rooms and lodging area. Support Team: Assist with repairs in the lodging area or production area. Fundraising: Help organize or participate in fundraising opportunities Fundraising: Serve on event committee Fundraising: Organize a collection drive for needed items (needs list located under Get Involved) Fundraising: Serve as a Lights Coordinator Fundraising: Participate in area events Fundraising: Assist with errands; picking up donations Office Help: Assisting with data entry, answer phones, special projects, greet visitors, process tote requests When are you available to work in the office? Only select if you are interested in volunteering in the office Morning 9-12 Afternoon 12-4 Monday Tuesday Wednesday Thursday Friday Once a week Twice a week Any other volunteer services not listed above that you would be interested in: Please read the confidentiality agreement & check the box to indicate you understand: * Information regarding Cancer Support Services recipients should be kept confidential at all times. The copyrighted Lydia pattern used for sewing Lydia totes cannot be reproduced or its likeness used for distribution, profit or personal use. I have read and understand the confidentiality agreement concerning Cancer Support Services recipients I have read and understand the confidentiality agreement concerning the Lydia totes Thank you for your interest in supporting Cancer Support Services and for your time in completing this application. All information remains confidential, helps CSS to better serve individuals undergoing cancer treatment, and allows the agency to learn more about you and your interests. Thank You!
