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Last Name *

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Email *

Company

Street Address (Home) *

City (Home) *

State (Home) *

Postal Code (Home) *

Country (Home)

Phone (including area code) *

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ACS Region you are from

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Staff or Volunteer (check one)

Staff

Volunteer

Progams in which you are currently involved (Please check all that apply)

Call Back Camp Discovery Shop DetermiNation I Can Cope Legislative Ambassador Look Good...Feel Better Making Strides Against Breast Cancer Man to Man Relay for Life Office Reach to Recovery Road to Recovery Support Group Other

If you have participated in others, please explain

When did you become an American Cancer Society volunteer?

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Your Relationship to Cancer (choose all that apply)

Cancer Patient Cancer Survivor Caregiver Family Member has/had Cancer Medical Professional Other

If you are a Patient/Survivor, please select the original site of diagnosis

Breast Colorectal Lung Prostate Skin Other

If Other, Please Explain

Race/Ethnicity

African American/Black American Indian/Alaska Native Asian Caucasian/White Hispanic/Latino Multiracial Pacific Islander Prefer not to answer Other

Languages Spoken (check all that apply)

Chinese (Mandarin) Chinese (Cantonese) English French German Italian Japanese Korean Spanish Vietnamese Tagalog

Please list any other languages spoken not listed above.

What sexual orientation do you most closely identify with?

Bisexual Gay Heterosexual Lesbian Prefer not to answer Other

Gender

Female Male Transgender Other

Birth Date

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How did you hear about volunteering opportunities with the Society?

American Cancer Society office Community service organization Discovery Shop Employer Faith based organization Family member has received Society services in the past Family/friend Health professional I have received Society services in the past Making Strides Against Breast Cancer Print Ad Relay For Life TV Ad 1-800-227-2345 www.cancer.org Other

If you selected "Other" above, please explain.

Confidentiality Policy:
At your American Cancer Society (or “Society”), we take your concerns about privacy seriously, and we take every reasonable effort to protect it when we use, and in some cases may share, your information. The information we collect on this webpage will be used by the Society to better serve you and your community. For example, we may use your information to:
• Analyze and develop programs so that we can improve how we serve our constituents
• Implement targeted volunteer recruitment efforts to have volunteers that represent all of California’s diverse communities
• Develop future on-going learning opportunities that meet your needs
• Ensure that volunteer and staff backgrounds, language skills, and interests are optimally matched with cancer patients, caregivers and survivors to support their quality of life.
• Invite you to participate in upcoming trainings, events or workshops that are relevant to your volunteer or staff role.

To view the Society’s complete privacy policy or if you have any questions about the Society’s privacy standards, please click here

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