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VITAL VOLUNTEER APPLICATION
If you are interested in becoming a Vital Volunteer, then please fill and submit this form.
Yes! I would like to become a Vital Volunteer
No, I cannot volunteer at this time, but please keep me on your mailing list.
No, I cannot volunteer at this time. Please remove me from your mailing list.
Salutation:
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
[ Choose a State ] Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
Home Phone:
Work Phone:
e-mail:
Date of Birth (mm/dd/yyyy):
/ /
Gender:
Male Female
Race:
Caucasian/White African-American/Black Asian/Pacific Islander Latino/Hispanic Native American Other Please Specify
Are you currently employed? Yes No
If YES, where:
City, State:
Can you be contacted at your work number?
Yes No
Donor's Name:
Relation to you:
Donor's Date of Birth:
Donor's Date of Death:
Type of Transplant(s):
Date of Transplant:
Hospital:
Please List the Days and Times You are Available:
Please List the Amount of Time and Distance You are Willing to Travel:
I am interested in staffing a booth during special events I am interested in assisting Golden State Donor Services staff with office projects I am willing to be interviewed by the media I am interested in addressing groups about organ and tissue donation:
Grade School Students Jr./Sr. High School Students Civic and Service Groups Adults (ages 19+) Pre-Transplant Groups Minority/Culture Groups Religious Groups
Less than 25 people 25-50 50-100 100 or more
Please Choose: Golden State Donor Services Other Website Community Event Friend Other
Please list the organizations and/or civic groups to which you belong:
What are your reasons for volunteering?
Please share your story of how your life has been impacted by donation/transplantation:
Please share a little bit about your past volunteer experiences:
What skills and talents are you willing to share with Golden State Donor Services?
Tell us about your previous speaking experiences.
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