'Advocates for Life' Volunteer Program Questionnaire
Please complete this questionnaire if you are interested in becoming a volunteer in Donor Alliance 'Advocates for Life' volunteer program. Once you complete the form, click the submit button at the bottom.
Name and Contact Information
First name:
*
Last name:
*
Title:
Choose
Mr.
Ms.
Nickname:
Preferred Method of Communication:
Choose
E-Mail
Mail
Phone
*
Street 1:
*
Street 2:
City:
*
State:
Choose
AZ
CA
CO
FL
GA
IA
IL
KS
MD
MN
MT
NC
ND
NE
NJ
NM
NV
NY
OH
PA
SD
TX
VA
WA
WI
WY
*
Zip:
*
Best Contact:
Choose
Cell Phone
E-Mail
Fax
Home Phone
Pager
Website
Work Phone
Home phone:
*
OK to call me here
Work phone:
OK to call me here
Cell phone:
OK to call me here
Email1:
*
Email2:
Date of birth:
Month
Jan
Feb
Mar
Apr
May
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Jul
Aug
Sep
Oct
Nov
Dec
Day
1
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Year
2022
2021
2020
2019
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
*
(year optional)
I'm Willing to Commute:
Choose
0 - 5 miles
100+ miles
10-25 miles
25-50 miles
50-100 miles
5-10 miles
*
Gender:
Choose
Female
Male
*
Preferred Shirt Size:
Choose
Adult Large
Adult Medium
Adult Small
Adult X-Large
Adult X-Small
Adult XX-Large
Youth Large
Youth Medium
Youth Small
Youth X-Large
Youth XX-Large
*
Employer:
*
How did you learn about the program?:
Advocate/Volunteer
Centura Transplant Center
Children's Hospital Transplant Center
Donate Life Scavenger Hunt
Donor Alliance Aftercare Program
Donor Alliance Employee
Donor Dash
Donor Family Tribute
Driver License Office/ Driver Services
Friend or Family Member
Local Organization
Other
Other OPO
P/SL Transplant Center
Special Event
UCH Transplant Center
Web Site
Your Connection to Organ & Tissue Donation
Recipient/Transplant Candidate:
Choose
Bone
Cornea
Double Lung
Heart
Heart/Lung
Kidney
Kidney/Pancreas
Liver
Lung
Pancreas
Tissue
Your Transplantation Date:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2042
2041
2040
2039
2038
2037
2036
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
Transplant Center/Location of Donation:
Your Loved One's Passing Date:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2042
2041
2040
2039
2038
2037
2036
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
What did your loved one donate?:
Specify your affiliation with organ and tissue donation (ie. Recipient of, transplant candidate for, relative of a recipient of, donor family member & was your loved one an organ and/or tissue donor, and what is your relation to the recipient or donor if you are a family member?)
Computer Knowledge & Other Applicable Skills
Computer Knowledge:
10-key
Adobe Acrobat
Adobe Distiller
Adobe Illustrator
Adobe InDesign
Adobe Photoshop
HTML
Instructional design/online instruction
Internet Proficiency
IT Support
Microsoft Excel
Microsoft Outlook
Microsoft Word
SharePoint
Web Content Manager
Foreign Languages:
Bahasa Indonesian
French
German
Hindi
Italian
Some French
Some German
Some Italian
Some Spanish
Some Ukrainian
Spanish
Ukrainian
Volunteer Opportunity Interests
*
Volunteer Preferences:
Donor Designation Stations
Media - Newspaper Stories
Media - TV stories
Office Work
Speakers Bureau
Special Events
Personal Story
Please share your personal story or interests with us as it relates to donation and/or transplantation.
Please type your personal story or interest as it relates to donation/transplantation here or send it to me in an email (Email: volunteers@donoralliance.org). Thank you!
Emergency Contact Information
First name:
*
Last name:
*
Home phone:
*
Cell phone:
Email address:
*
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Mother
Neighbor
Son
Spouse
Supervisor
Wife
*
Additional Enrollment Requirements
You will be required in-person to sign the Release of Liability, Privacy and Confidentiality Statement, Conduct Agreement and Background Screening Authorization for Advocates upon joining Donor Alliance's "Advocates for Life" volunteer program.
I Agree
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