Thank you for your interest in volunteering at Cancer Services. Date: (mm/dd/yyyy) Which volunteer position are you interested in? You may choose more than one. Supply Distributer Resource Center Volunteer Answering Phones Receptionist for Outreach Center @ Mary Bird Perkins, every Wed., 2 pm - 4 pm Supply Delivery : Donaldsonville, 3rd Mon. of every month, 11:00 am to 12:30 pm Supply Delivery : Gonzales, 3rd Mon. of every month, 1:00 pm to 2:30 pm Supply Delivery : Plaquemine, 2nd Mon. of every month, 1:00 pm to 2:30 pm Name:     Birthday:(mm/dd/yyyy) Address:   City   Zip: Home Phone:   Cell Phone:   Work Phone: Email: Would you like us to keep your employer abreast of your volunteer service and achievement? Yes No Available times: flexible weekends only weekdays only I am flexible. I prefer weekends. I prefer weekdays. What days and times are you available? Sunday      Monday      Tuesday     Wednesday Thursday    Friday        Saturday    Special Training, skills, hobbies... Groups, clubs, organizational memberships... Please describe your volunteer experience (include organization names and dates of service)... Have you ever been convicted of a crime? (If yes, please explain the nature of the crime and the date of the conviction and disposition.) Conviction of a crime is not an automatic disqualification for volunteer work. Yes No REFERENCES: Please list three people who know you well but are not relative and can attest to your character, skills, and dependability. Include your current or last employer. Name: Phone: Relationship: Length of Relationship: Name: Phone: Relationship: Length of Relationship: Name:Phone: Relationship: Length of Relationship: Please use this space to provide any other information or to express your interests. Lend us your knowledge and talents. For more information, email Cindi Tramonte, or call (225) 927-2273.