Membership Form – Circle of Strength

Date of Application *

mm/dd/yy

Name *

Last, First, Middle

Gender *

Female

Male

Street *

Street

City, State, Zip *

City, State, Zip

Your Email *

Home Phone *

Cell Phone *

Emergency Contact

Name, Relationship, Phone

Birthdate *

mm/dd/yyyy

Are you a cancer survivor or caregiver? *

Yes

No

If yes, date of cancer survivor's initial diagnosis: *

month and year

Or, touched by cancer (e.g. family, friend, worked in the field)? *

Yes

No

If a survivor or caregiver, how long since completion of the survivor’s treatment of initial cancer diagnosis *

years, months

Or is the survivor still in treatment for initial diagnosis? *

Yes

No

Have you ever been convicted of a crime? *

Yes

No

If yes, explain:

Previous job skills or volunteer experience:

advocacy, training, other cancer organizations/memberships

Areas of interest as a Volunteer:

Areas Willing to Volunteer:

I agree to volunteer at least 12 hours per year *

Yes

No

Please read: *

I hereby grant CSCS of AZ the right, license and privilege to use my name, likeness, photograph and voice in such a manner as CSCS of AZ deems appropriate in order to promote, advertize and publicize CSCS of AZ and its charitable activities. I hereby certify that all answers to the questions on this application are true, I understand and agree that any misstatement or omission of material facts contained in this application may disqualify me for a volunteer opportunity. I hereby authorize CSCS of AZ to verify the accuracy of the statements on this application.

Name *

Last, First, Middle