LifePreserver Volunteer Program Application
Name:
Date:
Address:
City:
Zip Code:
Phone (Home):
Phone (Work):
Cell:
Email (1):
Email (2):


Affiliation with LifeBanc
Transplant RecipientCandidate Transplant Type
Family Member/Friend of Transplant Recipient Candidate
Type of Transplant
Relationship to recipient/candidate
Donor Family Member    
Donor Name Donation Date

Location
Relationship to Donor  
Interested in promoting the cause of Organ and Tissue Donation
Areas of Interest for Volunteering

(For a description of the following volunteer positions, please see the LifePreserver Volunteer Program Opportunities)
Public Speaking School Programs Community/Corporate events
Marketing / Public Relations Office
Other - Please Specify
Avaliability: Weekdays Evenings Saturdays Sundays AM PM
Are you willing ot travel throughout the LifeBanc 20-county service area? Yes No

If no, what would be your limitations?

Any other special considerations:

Employment Status:
Full-Time Part-Time Self-Employed Retired Other
If employed, may we contact your employer regarding our Workplace Program? Yes No
Contact Name: Title:
Phone: Email:
Education: Completed High School
2-year College (Associate Degree)
 Some College
4-Year College (Bachelors)
Advanced Degree:
Other: (Please Fill in)

Please list any special skills you feel would be helpful: