Volunteer Application

Contact Information

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Date of Birth *

Gender *

Race/Ethnicity *

Employer or School

Special Skills/Interests, Certifications or Qualifications (select all that apply)

Special Considerations

Do you have any limitations, physical or otherwise, that we should know about so that we can make your volunteer experience a good one?

Yes

No

If yes, please explain:

Cancer Connections

Have you had any personal experiences with cancer?

Self

Other

None

Background Screening

Please be aware that answering Yes to one or more of the questions below will not automatically disqualify you from volunteering. If you answer Yes to any question(s) below, the Director of Outreach will set up a time to discuss the circumstances with you further.

1. Have you ever been convicted of a crime or do you have any pending charges against you? *

Yes

No

2. Have you ever been charged with or do you have any pending charges for child abuse or neglect? *

Yes

No

Referral

How did you hear about volunteering with Cancer Support Community Central Indiana?

Person to Notify in Case of Emergency

First Name

Last Name

Relationship *

Primary Phone Number

Alternate Phone Number

Please Note your General Availability

	Morning (8:30am-12:00pm)	Afternoon (12:00pm-5:00pm)	Evening (5:00pm-8:00pm)
Monday	Morning (8:30am-12:00pm)	Afternoon (12:00pm-5:00pm)	Evening (5:00pm-8:00pm)
Tuesday	Morning (8:30am-12:00pm)	Afternoon (12:00pm-5:00pm)	Evening (5:00pm-8:00pm)
Wednesday	Morning (8:30am-12:00pm)	Afternoon (12:00pm-5:00pm)	Evening (5:00pm-8:00pm)
Thursday	Morning (8:30am-12:00pm)	Afternoon (12:00pm-5:00pm)	Evening (5:00pm-8:00pm)
Friday	Morning (8:30am-12:00pm)	Afternoon (12:00pm-5:00pm)	Evening (5:00pm-8:00pm)
Saturday	Morning (8:30am-12:00pm)	Afternoon (12:00pm-5:00pm)	Evening (5:00pm-8:00pm)

Is there anything else you would like to share with us related to your volunteer experience?

For more information, please contact Rachel Kegerreis at 317-257-1505 or rachel@cancersupportindy.org.

CPR/First Aid	Babysitter Training
Foreign Language/Translation	Graphic Design
Art	Music
Event Planning	Writing
Health/Fitness Instructor	Office Work
Gardening/Landscaping	Photography
Public Speaking	Cooking/Meal Prep
Other Other

Social Media	School/Teacher
Current CSC Volunteer/Staff Member	Friend/Family Member
Workplace	Faith Community
Radio/TV/Newspaper	Other Other