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Young Survival Coalition > Community > Volunteer Program > Volunteer Application
Volunteer Application
Apply to be a volunteer!
All fields marked with an (*) are required
* First Name:
* Last Name:
Date of Birth (mm/dd/yyyy):
Male:  Female: 
Home Address:
City:    State:      Zip Code: 
* E-Mail Address:
* Please provide at least one phone number. If you provide more than one, please indicate preferred contact number:
   Home Phone:
   Work Phone:
   Cell Phone:
Are you a:
  Breast Cancer Survivor
  Medical Professional
  Friend/Family Member
  General Volunteer
How did you hear about us?
Other (please specify):   
Do you have access to the internet?
Yes   No
If so, do you have:
If Other, please specify:   
Do you have a valid drivers license?
Yes   No
If yes, do you have access to an automobile you can use for volunteer work?
Yes   No
Skills and Interests
Please select the highest level of education completed:
Current or Past Occupation:
Hobbies, Skills or Interests:
Previous Volunteer Experience:
Languages Spoken:
Preferences for Volunteering
Adopt-a-hospital
Community volunteer group
Public Speaking
Fundraising
News or Feature Writing
Point of Contact Program
Other (please specify):   
What time of day/week do you prefer to volunteer? (Check all that apply):
Weekdays
Weekends
No Preference
Day
Evening
No Preference
Please note: if you would like to apply for one of the specific volunteer opportunities listed on our website, please enter the title of the position here:
* References
Please type or print information for two non-family references who we may contact
Name:    
Address:       City:   
State:    Zip:   
E-Mail:       Phone Number:   
Name:    
Address:       City:   
State:    Zip:   
E-Mail:       Phone Number:   

I understand that:

1. The references I listed may be contacted directly by the staff of the YSC.
2. This application in no way obligates me to perform volunteer services
3. The YSC is not obligated to provide volunteer opportunities
4. Information I provide to the YSC is kept confidential. (The YSC does not sell/share information with any third party.)
* I accept the Terms and Conditions of YSC. Read our Privacy Policy.
If you prefer to complete and mail this form, click here for a printable version.

Please mail completed forms to:

Young Survival Coalition
Attn: Field and Volunteer Manager
61 Broadway, Suite 2235
New York, NY 10006
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Copyright 2005-2008 Young Survival Coalition. All rights reserved.
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