Are you ready to get involved? Great! Whether you volunteer for an hour or make a commitment over many months, your volunteer time is appreciated; as are you. There are a variety of ways you can get involved, and any needed training is provided. To get started, we need to know a little more about you. Submit the form below, and we will then contact you to discuss the opportunities available in your area that best match your interests and meet the needs of our mission. Thank you!

All fields marked with an * are required.

	* Have you ever volunteered with the American Cancer Society?
	Yes, I have volunteered within the past 12 months. Yes, I volunteered more than one year ago. I have never volunteered.
	Title
	Select... Mr. Mrs. Miss Ms. Dr.
	Name (*First Name, MI, *Last Name)
	Suffix
	Select... II III IV V VI Jr. Sr.
	Professional Degree (MD, PhD, RN)
	Select...MD RN DDS PhD Atty-at-Law CPA MA DMD LPN DO MEd Esq. MSW CLU MBA BSN JD DVM PA EDS DPM OD EdD AA PC RD DC RT PT RPh MSN MPH CFP LCSW BSW MPA C.N.A. CFSP NP SW A.D.N LMSW AD EMT
	Gender
	Select... Female Male
	* Home Address
	Home Address Line 2
	* City
	* State
	Select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Armed Forces AA Armed Forces AE Armed Forces AP
	* ZIP Code   -

	Birthdate
	Month January February March April May June July August September October November December 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 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

	Primary Phone	Extension	Type
	- -		Select... Home Cell Business
	Secondary Phone	Extension	Type
	- -		Select... Home Cell Business
	Primary Email		Type
			Select... Home Business
	( For Example: jvolunteer@example.com )
	Secondary Email		Type
			Select... Home Business
	* Preferred Method of Contact
	Select... Email Phone Mail

	Race:
	African American/Black
	American Indian/Alaska Native
	Asian
	Caucasian/White
	Hispanic/Latino
	Pacific Islander
	Other
	Please enter your race:
	Primary Language
	Select... American Sign Language Arabic (Saudi Arabia) Chinese (PRC) Chinese (Taiwan) Danish Dutch English-American English-British Finnish French French-Belgian German Hebrew International Sign Language Italian Japanese Korean Portuguese Portuguese-Brazilian Russian Spanish Spanish (Modern) Swedish Vietnamese Other Please enter your language:
	How would you like to volunteer for the American Cancer Society? (Select all that apply)
	Advocacy: I would like to become involved in legislative advocacy through your sister organization, American Cancer Society Cancer Action NetworkSM (ACS CAN).
	Education and Awareness: I would like to learn more about opportunities to share lifesaving prevention and early detection messages with my local community.
	Patient Service Programs: I am interested in opportunities to offer direct assistance to local cancer patients and their families.
	Administrative Opportunities: I would like to provide assistance in my local office by offering help with mailings, data entry, or other administrative duties.
	Community Events:
	Relay For Life ©: I am interested in helping on the day of the event.
	Relay For Life ©: I am interested in being on a planning committee.
	Relay For Life ©: I am interested in forming a team or being on a team.
	Making Strides Against Breast Cancer©: I am interested in helping on the day of the event.
	Making Strides Against Breast Cancer©: I am interested in forming a team or being on a team.
	I am interested in learning about other events in which I can participate
	I am passionate about activities related to:
	Select... Breast Colon/Rectal Lung Prostate Skin/Non-Melanoma Skin/Melanoma Other
	Other cancer types:
	Select... Bladder Bone Brain-Adult Brain-Child Breast Central Nervous System Cervix Colon/Rectal Endometrial Esophagus Eye Female Reproductive Gallbladder General Head & Neck Hodgkins-Lymphoma Kidney Larynx Leukemia-Adult Leukemia-Child Liver Lung Lung/Oral Lymphoma Multiple Myeloma Non-Hodgkins Lymphoma Oral Other Ovary Pancreas Penile Pharynx Prostate Psychosocial / Behavioral Sarcoma Skin/Melanoma Skin/Non-Melanoma Soft Tissue / Heart Stomach Testis Throat Thyroid Unknown/Unspecified Ureter Uterus Vagina Vulva
	* Have you ever been diagnosed with cancer?
	Select... Yes No
	My most recent cancer diagnosis was:
	Breast
	Colon/Rectal
	Lung
	Prostate
	Skin/Non-Melanoma
	Skin/Melanoma
	Other
	Other cancer types for most recent cancer diagnosis:
	Select... Bladder Bone Brain-Adult Brain-Child Breast Central Nervous System Cervix Colon/Rectal Endometrial Esophagus Eye Female Reproductive Gallbladder General Head & Neck Hodgkins-Lymphoma Kidney Larynx Leukemia-Adult Leukemia-Child Liver Lung Lung/Oral Lymphoma Multiple Myeloma Non-Hodgkins Lymphoma Oral Other Ovary Pancreas Penile Pharynx Prostate Psychosocial / Behavioral Sarcoma Skin/Melanoma Skin/Non-Melanoma Soft Tissue / Heart Stomach Testis Throat Thyroid Unknown/Unspecified Ureter Uterus Vagina Vulva
	My most recent date of diagnosis:
	Month January February March April May June July August September October November December 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 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
	Please indicate other ways that cancer has touched your life:
	I am/was a caregiver for someone who has/had cancer
	I have a friend who has/had cancer
	I have a relative who has/had cancer (Child, Partner, Spouse, etc)
	Current Employment Information:
	Job Title
	Company Name
	Company Address
	Company Address Line 2
	City
	State
	Select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Armed Forces AA Armed Forces AE Armed Forces AP
	ZIP Code   -