Komen Volunteer Release Form -

General Information

Name:	*      Date of Birth:
Street:	*
City:	*     State: *     Zip Code: *
Phone:	(home)      (work)      (cell)
Fax:	E-mail: To keep costs down, we use e-mail to let our volunteers know about upcoming events and opportunities so your e-mail address is very important to us. We will not distribute your email to anyone else.

Emergency Contact Information

Name:	Relationship:
Phone:	Cell:
Do you have any health issues that we should be aware of?

Interests and Availability

Job that you are interested in:

I am available throughout the year for: Race for the Cure     Health Fairs     Office Help     Special Events

I am a breast cancer survivor and would like to be included in Survivor Events: Yes     No

Please read the statements below carefully.
Check the box as confirmation of your understanding and agreement.

*	I wish to volunteer for the Indianapolis Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc. (the "Komen Affiliate"). I understand that the nature of volunteer activities that I may perform in my capacity as a volunteer may involve physical activity, contact with unidentified and/or unfamiliar persons, or other potential risk of bodily injury or damage to property. Knowing this and in consideration of being allowed to volunteer, I HEREBY ASSUME FULL AND COMPLETE RESPONSIBILITY FOR ANY PERSONAL INJURY AND/OR PROPERTY DAMAGE THAT I SUSTAIN OR CAUSE DURING MY PARTICIPATION AS A VOLUNTEER. IN ADDITION, I HEREBY RELEASE, HOLD HARMLESS AND COVENANT NOT TO FILE SUIT AGAINST THE KOMEN AFFILIATE, THE SUSAN G. KOMEN BREAST CANCER FOUNDATION, INC. (THE "FOUNDATION") AND ANY OF THEIR EMPLOYEES, VOLUNTEERS, PARTNERS, AGENTS, BOARD MEMBERS AND SUCCESSORS FROM ANY AND ALL LOSS, LIABILITY OR CLAIMS I MAY HAVE ARISING OUT OF MY SERVICE AS A VOLUNTEER. I understand that as a volunteer, I may become privy to confidential information about the Komen Affiliate or the Foundation. I agree to maintain the confidentiality of any information marked “confidential” as well as any information about the Komen Affiliate’s or the Foundation’s internal procedures, business operations, existing or prospective donor information, proprietary business information, personnel information and the like that is not otherwise publicly disclosed by the Komen Affiliate or the Foundation. I will not use any confidential information in any manner that would be detrimental to the Komen Affiliate or the Foundation, and I will avoid any actions that might impair the reputation of the Komen Affiliate or the Foundation.