Community Outreach

Youth and Education Programs
Faith-Based Communities
Donate Life Ambassadors
National Donate Life Month
How You Can Help - eCampaign

Donate Life Ambassador Application

If you are interested in becoming a Donate Life Ambassador, please complete and submit this form.

Donate Life Ambassador Options *

Yes! I would like to become a Donate Life Ambassador.
No, I cannot volunteer now, but please keep me on your mailing list.
No, I cannot volunteer now. Please remove me from your mailing list.

Salutation

Mr.
Mrs.
Ms.
Dr.

First Name *

Middle Initial

Last Name *

Street Address *

State *

Zip Code *

Home Phone *

Work Phone

Email Address *

Date of Birth

Gender

Male
Female

Race

Caucasian/White
African-American/Black
Asian/Pacific Islander
Latino/Hispanic
Native American
Other

Are you currently employed?

Yes
No

If Yes, List Address

Work State

Work Zipcode

May we contact you at your work number?

Yes
No

Reason for Volunteer Interest

I am a Donor Family Member

Yes
No

If Yes, Relationship to Donor

Donor's First Name

Donor's Last Name

Donor's Date of Birth

Donor's Date of Death

I am a Transplant Recipient

Yes
No

Type of Transplant(s)

Date of Transplant

Hospital

Areas of Volunteer Interest

Interest in becoming a high school classroom speaker
Interest in staffing a booth during special events
Interest in assisting GSDS staff with office projects
Interest in addressing groups about organ and tissue donation

How did you hear about Donate Life Ambassadors?

Golden State Donor Services
Other Website
Community Event
Friend
Other

Please list organizations and/or civic groups to which you belong:

What are your reasons for volunteering?

Share a story of the impact on you by donation/transplantation:

Share about your past volunteer experiences:

Please describe the skills and talents you would share with GSDS:

Describe your previous speaking experiences:

Sierra Donor Services | 1760 Creekside Oaks Drive, #220 Sacramento, CA 95833 | Toll-free 877-401-2546 | sds.info@dcids.org