Volunteer Application

* Required Fields

Date

First name*

Last name*

Birth date*

Main phone*

Cell*

Work

Email address*

Retype Email address*

Is email a reliable way to reach you?*

Yes

Address*

City*

State*

Zip Code*

County*

What languages do you speak?

Ethnicity (Optional)

I am most interested in working with...*

	General Public (Community Health Fairs, festivals, sports and cultural events) Multicultural Communities (Hispanic, African American and/or Asian outreach) Hospitals (Staff Presentations, hospital health fairs) Schools (Presentations to high schools, colleges and trade schools) Civic Organizations (Rotary clubs, Women’s Clubs, special interest organizations)		Faith-based Organizations (Presentations to congregations and religious groups)
	Media (Press conferences and on-camera and radio interviews)

Help us clearly understand your relationship to donation by completing all sections:

	I am a transplant recipient		I am a donor family member
	I am a living donor		I am someone on the waiting list
	Other

Please explain...

If you are a transplant recipient, what is the year of your transplant?

Name of Transplant Center

I would like to utilize the following skills

	Speaking		Tabling (Health Fairs)
	Media		Writing
	Photography/Videography		Web/Graphic Design
	Event Planning/Coordinating		Other

Describe how you have used these skills in past experiences

Availability: Please check what days and times you are usually available to volunteer for at least one hour.

How did you hear about Gift of Life Donor Program?

	Family member or friend		Gift of Life Speaker
	Civic Group		Gift of Life website
	Transplant Center or Hospital		Gift of Life mailing

I would like more information regarding the following volunteer groups listed in the brochure:

	Liaisons for Life (Philadelphia)		Hearts of Gold (Donor Families in Philadelphia)
	Multicultural Affairs (Philadelphia)		Southern New Jersey Coalition
	Central Susquehanna Coalition		Capitol Coalition
	Berks County Coalition		Central PA
	Northeast PA Coalition		Lehigh Valley Coalition
	Delaware Coalition North (Newark)		Delaware Coalition South (Dover)
	Southcentral PA

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