Komen Tidewater Affiliate
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Name:
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Address 1:
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Address 2:
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City:
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Zip:
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Home Phone:
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Work Phone:
Fax:
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Email:
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Employer:
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Occupation:
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Emergency Contact:
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Phone:
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The following personal data is for
analytical purposes only:
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Date of Birth:
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Gender:
Male
Female Race:
(Select one)
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Do you have any physical limitations
or illnesses that we should know about? If so, please tell
us about them.
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Would you like to be recognized
as a breast cancer survivor? | If so, when was your last
treatment?
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Do you agree with these terms?
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Volunteer support is needed for
the following areas. Please mark your top 3 choices.
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Komen Tidewater Race for the Cure®.
Help plan the Affiliate's signature event. Race subcommittees
include: Registration, Logistics, Sponsorships, Survivor
Recognition, Kids for the Cure®, and more.
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BMW Ultimate Drive®.
Help coordinate the Affiliate's involvement in this one-day
event with the local BMW dealerships.
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Pink Tie Gala. Help the Affiliate
plan a formal dinner, dance, and silent auction fundraiser.
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Pink Martini Night.
Plan this cocktail party and silent auction fundraiser.
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Education. Help
the Affiliate plan ways to disseminate breast health information.
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Survivors. Plan
and implement ways to support, celebrate, and involve breast
cancer survivors.
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Volunteer. Recruit,
place, and train volunteers for various Affiliate events
and activities.
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Communications.
Identify and implement ways to promote Komen Tidewater Race
and other special events.
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Fundraising. Solicits
cash sponsorships and in kind donations of goods and services
for Affiliate events and activities.
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Passionately Pink for the Cure™.
Help the Affiliate promote participation in Pasionately
Pink by encouraging companies, schools, and groups to designate
a day (or two) in october to wear pink and learn about breast
cancer prevention.
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Administrative/Office Support. Provide
administrative support to the Komen Tidewater Office; assist
with materials preparations, bulk mailings, data entry,
filling in at the office, etc.
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Do you have any special skills that
could benefit the Affiliate? (i.e. graphic design, etc):
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I am available to volunteer:
During the Day
Nights
Weekends
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Please indicate what degree of volunteer
commitment you are willing to make at this time. Check all
that apply.
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Willing to Commit Time Every Week. Time
commitment may include working at the Komen Tidewater Office
for a designated number of hours each week.
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Willing to Commit Several Hours a Month.
Time commitment may include attending a monthly meeting
(estimated 2 hours) or spending a few hours a month working
on committee assignments.
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Willing to Commit Block of Time at Periodic Intervals.
Requires a time commitment of a couple of hours at various
times during the year to help with a special event or task.
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Willing to Work on Event Day only. Time
commitment may include attending a pre-event volunteer orientation.
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|||||||Tidewater Affiliate of Susan G. Komen for the Cure