Volunteer Form

Please complete the following information and return it to: Regenerations Wellness Cancer Foundation, P.O. Box 186, Los Banos, California 93635-0186

Are you interested in forming a community partnership, starting a support group, volunteering, donating space for a class, seminar or wellness event to reach cancer survivors ?

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Name
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Address
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City & Zip
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Home Phone
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Work Phone
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Cell Phone
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Email
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Place of Employment
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Position
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Emergency Contact Person and phone #

   Special Skills or Talents – List anything you’d like us to know about you.

   Community Connections – List other organizations in which you are involved.

   Professional Credentials – Please list any information which may be helpful for us to know.

   Other pertinent information – List any additional info about you that will help us utilize your skills and talents the best way possible, including your personal cancer connection or why you desire to be involved with Regenerations Cancer Wellness Foundation.

Skills & Interests

Please CIRCLE your skills and interests (Please indicate if you can perform a skill: Very Well -   Well - So-So -   Not at All)
Computer skills: Microsoft Word, Photo shop, Excel, PowerPoint, Web Design, other
Speaking :Public, Express ideas
Office Skills-mailings, newsletters
Writing: grants, reports, articles
Outreach & Special Events
Seminars, health education
Books- restorative wellness, affirmations etc
Artistic Skills: drawing, painting, photography
Gardening
Fundraising
Meeting new people
Other languages (speak , read, write

Special or Unique Talents(explain)

REFERENCES (one personal & one professional preferred)

Name___________________________________________________________________

Address_________________________________________________________________

Phone__________________________________________________________________

Relationship _____________________________________________________________

Name___________________________________________________________________

Address_________________________________________________________________

Phone___________________________________________________________________

Relationship ______________________________________________________________


PERSONAL INFORMATION

Are you a cancer survivor or family member of cancer survivor?

   Yes; Explain: ______________________________________


Please READ AND SIGN

I certify that all information given on this volunteer application is true, complete, and correct.

Birth Date___________________________________

Applicants Signature

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Date _____________