Volunteer Application
Please fill out this form and we will contact you regarding volunteering with LCI

Please contact Alisha Patel, Community Engagement Manager with any questions.

apatel@lungcancerinitiative.org
Email *
Name: *
  Street Address, City, State, ZIP Code: *
Phone Number: *
Date of Birth: *
T-Shirt Size: *
Required
During which hours are you available for volunteer assignments? Select all that apply. *
Required
Tell us in which areas you are interested in volunteering? Select all that apply.
 *
Required
If you are a NEW volunteer, please summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports.  

If you are a returning volunteer, please type N/A.
 *
If you are a NEW volunteer, summarize your previous volunteer experience.

If you are a returning volunteer, please type N/A.
 *
NEW applicants only..
Please list two professional references (References cannot be family members or friends).

Returning volunteers, please type N/A.
 *
Emergency Contact (Name, relation, phone number, and email): *
By submitting this application, I affirm that the facts set forth in it are true and complete. 

As a volunteer of our organization, I understand that I will be volunteering at my own risk and that the organization, its employees and affiliates, cannot assume any responsibility or any liability for any accident, injury or health problem which may arise from any volunteer work I perform for the organization. I agree that all the work I do is on a volunteer basis and I am not eligible to receive any monetary payment or reward.

I have read and understand the Lung Cancer Initiative Volunteer Orientation slides. I understand that from photos taken during volunteer hours my likeness may be used in future marketing and promotional materials for the Lung Cancer Initiative. 

I also agree to protect the confidentiality of all individuals associated with the Lung Cancer Initiative. I recognize that any and all information shared with me as part of my duties as a volunteer shall not be divulged to unauthorized individuals, agencies, or organizations. I will not copy, transcribe, record, or memorize confidential information in any manner, nor disclose or use such information for any purpose other than for the limited purpose of providing the assigned services at the Lung Cancer Initiative. 

BY SIGNING BELOW, I accept and agree to the terms contained above.  

Name (signature) and date:
 *
A copy of your responses will be emailed to the address you provided.
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