Membership Form 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: Administrative Community Outreach Events Fundraising Peer Support (Additional orientation required) Special Projects Other Areas Willing to Volunteer: Central Phoenix North Phoenix Tempe/West Mesa Chandler/Ahwatukee Glendale/Peoria East Valley/Gilbert Scottsdale 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 If you are human, leave this field blank.