Sign in if you already have an account.
         
Susan G. Komen
   
donate.gif
National Spotlight

Financial Resources — Did you know that there are many financial resources that can help people living with breast cancer? Find out more

Rally for the Cure — Golf, tennis, dinner events and so much more...

Go Passionately Pink to help save lives! — Just wear pink, have fun and raise money to fight breast cancer. Be inspired by the multitude of ideas right here, or think of your own. There are so many creative ways to have fun and fight breast cancer.

Central Indiana - Volunteer Application & Waiver

 

Volunteer Application

*
Question - Required - Title
Please make 1 selection from the choices below.

  Your information:

*

Name:

 

 

   

*

*

City/State/ZIP:

 

    

   


   


   


  Preferred Email

*

 


*
Question - Required - Please contact me by
Please make 1 selection from the choices below.

   


   


*
Question - Required - Have you ever been convicted (including entering a plea of guilty or nolo contendere) of any felony crimes with in the past 7 years?

 

*Do not include convictions that were sealed or expunged pursuant to a court order*

 

A "yes" is not an automatic bar to volunteer service with the [Susan G. Komen Central Indiana]; the circumstances relating to the offense will be considered in relation to the voluneer position for which you are applying

*
Question - Required - Are you a breast cancer survivor?

   


 

*
Question - Required - Have you volunteered in the past for Susan G. Komen Central Indiana, another Affiliate or Komen Headquarters?

 

Optional

Susan G. Komen Central Indiana seeks to collect and analyze volunteer data in mannger that allows us to meaningfully examine our progress in developing an inclusion organization. The data is useful for self-monitoring to maintain our dedication to creating a caring environment that demonstrates respect for all people through our words and actions. Completion of this section is voluntary and will not affect your ability to volunteer for Komen. Information provided will be confidential.

 
Question - Not Required - Date of Birth




 
Question - Not Required - Gender

 
Question - Not Required - Race / Ethnicity
Please make up to 6 selections from the choices below.

 

Skills and Availability

*
Question - Required - Please indicate if you have more than one year of experience in the following areas

   


*
Question - Required - How often would you like to volunteer?

*
Question - Required - Are you available to volunteer on WEEKDAYS?

*
Question - Required - Are you available to volunteer on WEEKENDS?

*
Question - Required - Are you available to work EVENINGS?

 

Volunteer Opportunities

Please SELECT all that may be of interest to you.

 
Question - Not Required - Education Outreach Efforts

 
Question - Not Required - Administrative Efforts

 
Question - Not Required - Mission Initiatives

 
Question - Not Required - 2014-2015 Susan G. Komen Central Indiana Sponsored Events-Help plan and implement the following events:

 

Emergency Contact Information:

   


   


   


 

Information to Volunteer Applicants

(Read Carefully Before Signing)

You may be asked to sign an authorization for the Susan G. KomenŽ Central Indiana to fully investigate your suitability for volunteering (depending on the position and responsibilities) by obtaining information from your previous employers and/or other knowledgeable persons as to their firsthand experiences with you, and also, when deemed necessary, by obtaining reports from credit bureaus, credit agencies, or other consumer reporting agencies.  Under some circumstances, certain of such reports may be “consumer reports” or "investigative consumer reports" as to which, under the Fair Credit Reporting Act, you are entitled, upon your request in writing, to receive a complete and accurate disclosure of the nature and scope of the investigation requested by the Susan G. KomenŽ Central Indiana .

 

Volunteer Applicant Statement

(Read Carefully Before Signing)

I certify that I completed this volunteer application and that all the answers to the questions on this volunteer application and any attachments are to the best of my knowledge true and correct and that I have not knowingly withheld any pertinent facts or circumstances all of which are subject to validation.  I understand that any misrepresentation, false statement, or omission made by me with respect to the information contained in this volunteer application could disqualify me from consideration as a volunteer, or if selected as volunteer, result in the termination of my volunteer efforts from the Susan G. KomenŽ Central Indiana .
If selected as a volunteer, I agree to comply with the rules and regulations of Susan G. KomenŽ Central Indiana .  
I also understand that smoking is prohibited in all indoor areas of the Susan G. KomenŽ Central Indiana .

 

Komen Volunteer Release

I wish to volunteer for the Indianapolis Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc. d/b/a Susan G. KomenŽ Central Indiana (“Komen Affiliate”).  I understand that my consent to these provisions is given in consideration for being permitted to volunteer for 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 OR UNFAMILIAR PERSONS, OR OTHER POTENTIAL RISK OF BODILY INJURY OR DAMAGE TO PROPERTY AND I HEREBY VOLUNTARILY ASSUME FULL AND COMPLETE RESPONSIBILITY FOR, AND THE RISK OF, ANY INJURY OR ACCIDENT WHICH MAY OCCUR DURING MY VOLUNTEER WORK WITH THE KOMEN AFFILIATE.  TO THE FULLEST EXTENT OF THE LAW, I, FOR MYSELF, MY NEXT OF KIN, MY HEIRS, ADMINISTRATORS, AND EXECUTORS (COLLECTIVELY, “RELEASORS”), HEREBY RELEASE AND HOLD HARMLESS AND COVENANT NOT TO FILE SUIT AGAINST (I) THE KOMEN AFFILIATE, THE SUSAN G. KOMEN BREAST CANCER FOUNDATION, INC. D/B/A SUSAN G. KOMEN (“KOMEN HEADQUARTERS”), AND ALL OTHER AFFILIATES OF KOMEN HEADQUARTERS AND THEIR RESPECTIVE DIRECTORS, OFFICERS, VOLUNTEERS, AGENTS AND EMPLOYEES; AND (II) ALL OTHER PERSONS OR ENTITIES ASSOCIATED WITH THE KOMEN AFFILIATE OR KOMEN HEADQUARTERS (COLLECTIVELY, THE “RELEASEES”) FOR ANY INJURY OR DAMAGES I MIGHT SUFFER IN CONNECTION WITH MY VOLUNTEER WORK WITH THE KOMEN AFFILIATE.  THIS RELEASE APPLIES TO ANY AND ALL LOSS, LIABILITY, OR CLAIMS I OR MY RELEASORS MAY HAVE ARISING OUT OF MY VOLUNTEER WORK WITH THE KOMEN AFFILIATE, INCLUDING BUT NOT LIMITED TO, PERSONAL INJURY OR DAMAGE SUFFERED BY ME OR OTHERS, WHETHER SUCH LOSSES, LIABILITIES, OR CLAIMS BE CAUSED BY CONTACT WITH AND/OR THE ACTIONS OF OTHER PERSONS, CONTACT WITH FIXED OR NON-FIXED OBJECTS, NEGLIGENCE OF THE RELEASEES, RISKS NOT KNOWN TO ME OR NOT REASONABLY FORESEEABLE AT THIS TIME, OR OTHERWISE.

I understand that as a volunteer, I may become privy to confidential information about a Releasee. I agree to maintain the confidentiality of any information marked “confidential” as well as any information about each Releasee’s business operations, organizational structure, employee information, financial operations, marketing strategy, organization, donor lists and amounts, plans for upcoming events, current or proposed business transactions and sponsorships, and any proprietary information such as computer software and programming and the like that is not otherwise publicly disclosed.  I will not use any confidential information in any manner that would be detrimental to a Releasee.

At all times during my volunteer work with the Komen Affiliate, I will conduct myself in such a manner as not to reflect unfavorably on or in any way diminish the reputation of the Komen Affiliate, Komen Headquarters and its affiliates.  

I give my consent and permission to the Komen Affiliate, Komen Headquarters and its respective affiliates, successors, licensees, and assigns the irrevocable right to use, for any purpose whatsoever and without compensation, any photographs, videotapes, audiotapes, or other recordings of me that are made during the course of volunteering with the Komen Affiliate.

This Release shall be construed under the laws of the state in which the Komen Affiliate is located.  In the event any provision of this Release is deemed unenforceable by law, (i) the Komen Affiliate shall have the right to modify such provision to the extent necessary to be deemed enforceable; and (ii) all other provisions of this Release shall remain in full force and effect.  

I understand that I have given up substantial rights by signing this Release, and have signed it freely and voluntarily without any inducement, assurance or guarantee being made to me and intend my signature to be a complete and unconditional release of liability to the greatest extent allowed by law.

*  


   


 
   Please leave this field empty