Volunteer Application

Thank you for your interest in the Colon Cancer Alliance (CCA). Our impact as an organization is directly linked to the quality and dedication of our volunteers. Help us increase colon cancer survivorship and screening rates!

Name/Address:

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Name:

First Required	Middle Required	Last Required

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Email: Required

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Street 1: Required

Street 2:

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City/State/ZIP:

City Required	State Required	ZIP Required

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Date of Birth: Required

Date of Birth:

Month

Day

Year

Question - Not Required - Gender

Question - Not Required - Race/Ethnicity

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Question - Required - Home Phone Number

Question - Not Required - Cell Phone Number

Question - Not Required - Work Phone Number

Question - Not Required - What other languages do you speak?

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Which of the following best describes your connection to colon cancer?

Question - Not Required - Within the last six months, were you or a loved one diagnosed with colon cancer?

How would you like to get involved? Please check all that apply.

	Buddy Peer-to-Peer Program
	Represent the CCA at a local or national health fair or trade show
	Do a Fundraiser
	Undy 5000 5K Run/Walk
	Primary Care Provider Outreach Program
	Dress in Blue Day

Question - Not Required - If you selected Undy 5000 as a year round project, what city can you volunteer in?

Question - Not Required - Other Skills/Interests:

(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - Have you ever been convicted of a felony?

Question - Not Required - If yes, please explain.

(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - I give permission for the CCA to conduct a police clearance check.

Question - Not Required - How did you hear about the Volunteer program? (select all that apply)

	Colon Cancer Alliance Volunteer or Staff Member
	Healthcare Professional (Doctor, Nurse, etc.)
	Facebook, Twitter or other Social Media
	Colon Cancer Alliance email or website
	My CRC Connections
	Word of Mouth
	Other

Question - Not Required - If other, please specify:

By submitting this form, I certify that all statements made on this form are true, complete, and correct.

Note: All information you provide will be kept confidential. We accept applicants for all positions without regard to age, color, creed, disability, handicap, height, weight, marital status, national origin, race, religion, sex, sexual preference, or liability for service in the armed forces.