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Komen Volunteer Release Form

El Paso Affiliate of Susan G. Komen For The Cure

Contact Information:
(*required)
*Name:
*Date of Birth (mm/dd/yyyy):
*Street:
*City:
*State:
*Zip-Code:
*Phone (Home):
Phone (Work):
Phone (Cell):
Employer:
Address:
Fax:
*E-mail:
Emergency Contact Information:
Name:
Relationship:
Phone:
Personal Information:
Do you have any health issues/restrictions that we should be aware of?Yes   No
If yes, please provide an explanation:
Areas of Expertise:
Administration/Management
Technology
Financial Management
Accounting
Banking & Trusts
Investments
Fundraising
Education
Healthcare
Legal
Marketing/Public Relations
Human Resources
Strategic Planning
Non-Profit
Public Policy

Availability:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 
Morning
Afternoon
Evening
Flexible
Only Weekend

I am interested in volunteering throughout the year for:
Health Fairs
Office Help
Special Events
Speaking Engagements
Fundraising
Public Policy

I am a Breast Cancer Survivor:
No: Yes:

Agreement:

I wish to volunteer for the El Paso Affiliate of Susan G. Komen for the Cure (the "Komen Affiliate"). I understand that the nature of volunteer activities that I may perform in my capacity as a volunteer may involve physical activity, contact with unidentified and/or unfamiliar persons, or other potential risk of bodily injury or damage to property. Knowing this and in consideration of being allowed to volunteer, I HEREBY ASSUME FULL AND COMPLETE RESPONSIBILITY FOR ANY PERSONAL INJURY AND/OR PROPERTY DAMAGE THAT I SUSTAIN OR CAUSE DURING MY PARTICIPATION AS A VOLUNTEER. IN ADDITION, I HEREBY RELEASE, HOLD HARMLESS AND COVENANT NOT TO FILE SUIT AGAINST THE KOMEN AFFILIATE, SUSAN G. KOMEN FOR THE CURE (KOMEN) AND ANY OF THEIR EMPLOYEES, VOLUNTEERS, PARTNERS, AGENTS, SPONSORS, BOARD MEMBERS AND SUCCESSORS FROM ANY AND ALL LOSS, LIABILITY OR CLAIMS I MAY HAVE ARISING OUT OF MY SERVICE AS A VOLUNTEER.

I understand that as a volunteer, I may become privy to confidential information about the Komen Affiliate or Komen. I agree to maintain the confidentiality of any information marked "confidential" as well as any information about the Komen Affiliate's or Komen's internal procedures, business operations, personnel information and the like that is not otherwise publicly disclosed by the Komen Affiliate or Komen. I will not use any confidential information in any manner that would be detrimental to the Komen Affiliate or Komen, and I will avoid any actions that might impair the reputation of the Komen Affiliate or Komen.


*I have read and agree to the terms of the agreement

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