Date *

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

Country

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

My employer matches volunteer hours *

Yes

No

Unsure

N/A

What volunteer activities are you interested in? *

Check all that apply

Event Coordination

Partnership / Sponsorship Administrator

Campaign / Fundraising Support

Volunteer Coordination

Medical Outreach / Education

Marketing Support

Shades of Teal Administrator

Authorization *

I certify that the answers given in this application are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application as may be necessary for the purposes of determining an appropriate and satisfactory volunteer position for me, including contacting my references. I understand that this application is not, and is not intended to be, a contract. I understand that false or misleading information provided in my application or interview may result in my not being able to continue as a volunteer with PCOS Awareness Association.

Yes

No

Media Release *

In signing below, I agree to be photographed, videotaped, and/or recorded while volunteering with PCOS Awareness Association. I understand that PCOS Awareness Association will own rights to and may use this media (photographs, videos, audio recordings, and/or my statements), in whole or part, in PCOS Awareness Association materials such as printed publications, the PCOS Awareness Association website (www.pcosaa.org), videos, social media, grant proposals, and promotional materials to support PCOS Awareness Association and its programs. As far as I know, what I say and do in this media will not violate the rights of any other person or company. If I no longer want my photos and/or story to be used, I agree to contact PCOS Awareness Association at office@pcosaa.org. Once requested, PCOS Awareness Association will not create new materials using participants’ media – but we may continue to use already printed materials until we can make replacements.

Yes

No