• Facebook
  • Twitter
  • YouTube
  • Flickr
Toggle Menu

Community Outreach Volunteer - Interest Form

  Volunteer Application
*1.
Question - Required - Date




2. Your information:

*

Name:

 

 

   

*

*

*

City/State/ZIP:

 

    

*

*

*

 

*

Date of Birth:

 

 

 


*3.


*4.


 

NOTE: Before answering this question regarding criminal convictions please refer to the instructions below if you reside or are applying for a position in Alaska, California, Connecticut, District of Columbia, Georgia, Hawaii, Massachusetts, Ohio or Washington.

INSTRUCTIONS FOR ANSWERING CRIMINAL CONVICTION INQUIRY

California Applicants:  Do not identify convictions under California Health & Safety Code §§11357(b) or (c), 11360(b) (formerly subdivision (c) of section 11360), 11364, 11365, or 11550 related to marijuana offenses that occurred two or more years before the instant application.  Also, do not identify any conviction for which the record has been judicially ordered sealed, expunged or statutorily eradicated, or any misdemeanor conviction for which probation has been successfully completed or otherwise discharged and the case has been judicially dismissed.

5.  


6.

7.  


*8.

*9.

10.  


 

I wish to volunteer for Susan G. Komen Northern & Central California. 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.

*11.  


12.  


 

Information for Volunteer Applicants

(Read Carefully Before Signing)

You may be asked to sign an authorization for Susan G. Komen Northern & Central California 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 Susan G. Komen Northern & Central California.

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 a volunteer, result in the termination of my volunteer efforts from Susan G. Komen Northern & Central California.

If selected as a volunteer, I agree to comply with the rules and regulations of Komen Northern & Central California. 

I also understand that smoking is prohibited in all indoor areas of Komen Northern & Central California. 

Komen Volunteer Release

I wish to volunteer for the Northern & Central California Affiliate of the Susan G. Komen Breast Cancer Foundation d/b/a Susan G. Komen Northern & Central California (“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 AFFILIATETO 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 (“KOMEN HEADQUARTERS”), AND ALL OTHER AFFILIATES OF KOMEN HEADQUARTERS 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, 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 give my consent and permission to the Komen Affiliate, Komen Headquarters and its respective affiliates, successors, licensees, and assigns the irrevocable right to use, for any purpose whatsoever and without compensation, any photographs, videotapes, audiotapes, or other recordings of me that are made during the course of volunteering with the Komen Affiliate.

This Release shall be construed under the laws of the state in which the Komen Affiliate is located.  In the event any provision of this Release is deemed unenforceable by law, (i) the Komen Affiliate shall have the right to modify such provision to the extent necessary to be deemed enforceable; and (ii) all other provisions of this Release shall remain in full force and effect.

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.

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.]

*13.  


 

Thank you for your interest in volunteering as a Bilingual Community Outreach Volunteer for Susan G. Komen Northern & Central California. We appreciate your offer to share your time and talents with us. We will contact you once we have received your completed application.

   Please leave this field empty