VOLUNTEER INTEREST FORM

VOLUNTEER INTEREST FORM

Thanks so much for being here! Go ahead and fill this out completely! We'll be getting back to you!
Full Name*

First NameLast Name
E-mail*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Are you over 18?*

YesNo
Where did you hear about us?*
EMERGENCY CONTACT
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
RELATIONSHIP*
SURVIVOR INFORMATION

NOT a survivor? Totally okay! Skip this section. TO OUR SURVIVORS: we ask these questions for possible peer navigation pairing and support. It helps Carrie's TOUCH better assess the requests of our survivors. These questions are optional, and we appreciate any information you chose to share.
ARE YOU A BREAST CANCER SURVIVOR?

YESNO
Type of Breast Cancer
Stage
List of surgeries, if applicable
Please click all that apply.

I had chemotherapy.I had radiation.I have been diagnosed more than once.I had surgery.Other
VOLUNTEER INFO
DO YOU LIVE IN SACRAMENTO? *

YESNO
DO YOU LIVE IN CALIFORNIA? *

YESNO, BUT I'M EXCITED ABOUT REMOTE VOLUNTEERING!
Please tell us your average availability.*

My mornings are freeMy afternoons are freeMy evenings are freeMy weekends are free
Tell us about yourself! What are your hobbies/interests? *

0/50
What would you say is your "super power" or skill?*

0/50
Please let us know to the best of your ability, where you could best serve Carrie's TOUCH. Please read all of our teams before making a decision. We ask that you only pick a maximum of TWO areas of interest. We don't want to spread you thin!
TEAM SURVIVORS**

Team Survivors works directly with Breast Cancer survivors to provide, support, advocacy, peer counseling, and at times even attending treatments with survivors.

**Volunteers who are Breast Cancer survivors themselves are preferred in this role.
TEAM MEDIA & BRANDING

Do you love social media? Research? Reaching out to influencers? Team Marketing and Branding is for YOU! We need help getting CT's work out there! Even if you aren't a social media expert, we could use your help!
TEAM LEVEL UP

If raising money is your jam, welcome to Team LEVEL UP! Whether it's grassroots fundraising or grants writing, we need your help making sure Carrie's TOUCH can continue to do incredible work in the community.
TEAM EVENTS

Carrie's TOUCH hosts events both live and virtual all year long. Implementation, planning, set up and so many more hands are needed to ensure its success. If event planning is your vibe, get in here!
TEAM ACTIVATE

Team Activate is Carrie's TOUCH's army of on-call angels who are ready, willing, and able to support survivors anyway they need. Be it an urgent ride to chemo, medication delivery, phone banking or an emergency sit-in at the state capitol, Team Activate is ready to mobilize at any given point.
TEAM CHANGE

Team Change is Carrie's TOUCH's specialized team of advocates set up to implement changes in our government, legistlature, and laws. City, county, state or federal, Carrie's TOUCH is always ready to mobilize, get the word and the vote out for policies and changes that impact our communities and our survivors. If grassroots organizing and policy-making is your jam, this is your team!
PLEASE CHOOSE A TEAM THAT BEST SUITS YOUR INTERESTS, PASSION AND SKILLS! (Please only pick a maximum of TWO areas of interest.)*

TEAM SURVIVORSTEAM EVENTSTEAM MEDIA & BRANDINGTEAM LEVEL UPTEAM ACTIVATETEAM CHANGE
HIPAA CONFIDENTIALITY AGREEMENT

As a volunteer of Carrie’s TOUCH, you may have access to confidential information, both written and oral, in the course of your responsibilities. It is imperative that this information is not disclosed to any unauthorized individuals to maintain the integrity of those we serve and their privileged, private, and/or medical information. An unauthorized individual would be any person that is not currently an employee, volunteer, and/or any information. Any other disclosures may only occur at the direction of Carrie’s TOUCH co-founder and CEO TAMMIE DENYSE or by patient authorization.

I have read and understand Carrie's TOUCH’s policies with regards to privacy and Security of personal health information. I agree to maintain confidentiality of all information obtained in the course of my volunteerism including, but not limited to, financial, technical, or propriety information of the organization and personal and sensitive information regarding patients, employees, and vendors. I understand that inappropriate disclosure or release of patient information is grounds for release from duties and possible legal penalties under California State law.
I AGREE TO THE ABOVE HIPAA CONFIDENTIALITY AGREEMENT.*

YESNO
MEDIA RELEASE

Images, video, and audio recordings of myself taken or recorded by CARRIE'S TOUCH can be used in print, broadcasting or other forms of marketing and advertising: brochures, newsletters, reports, publications, online, CARRIE'S TOUCH website, Twitter, Facebook, Instagram, and YouTube. Additionally, audiovisual presentations and other activities to promote the entity CARRIE'S TOUCH and inform the public about the non-profit and its work.

These photos, video, or other images or recordings may be used by CARRIE'S TOUCH without payment of fees, royalties, or other remuneration.

CARRIE'S TOUCH agrees images will never be used in a derogatory manner nor to defame the character or personage of the signee.
I AGREE TO THE ABOVE MEDIA RELEASE.*

YESNO
I authorize that I am over the age of 18.*

YESNO
Signature*

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VOLUNTEER INTEREST FORM

EMERGENCY CONTACT

SURVIVOR INFORMATION

VOLUNTEER INFO