New Volunteer Survey

Contact Information and Availability

Thank you for your interest in volunteering with Chemo Comfort. We encourage you to view our website at www.chemocomfort.org so that you understand our mission and Chemo Comfort kits. Please fill out all of the information below so that we have a clear idea about the experience you are looking for and the time that you are able to give.

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1. Please enter the date.

	MM		DD		YYYY
Today's Date	Please enter the date. Today's Date Month	/	Day	/	Year

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2. Please provide the following contact information:

Please provide the following contact information: Name
Address (Number and Street)
Address (City, State, and Zip)
E-Mail Address
Phone Number(s)
Date of Birth

3. How did you hear about Chemo Comfort?

How did you hear about Chemo Comfort? Brochure chemocomfort.org Event	Friend or Family Member Google idealist.org	Meet-up group Other Website
Other (please specify)

4. If you have a car, would you be willing to use it to help transport materials to events or deliver kits to partner organizations?

If you have a car, would you be willing to use it to help transport materials to events or deliver kits to partner organizations? Yes

N/A

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