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Volunteer details
* required fields
Today's date:
*
Were you a CanCare client:
*
Yes
No
Where did you learn about CanCare?:
First name:
*
Last name:
*
Spouse's name (if applicable):
Date of birth:
*
Languages spoken (other than English):
Children:
Yes
No
If you have children, please list the number of children and their ages:
Home phone:
*
Cell phone:
Office phone:
Email:
Home street address:
*
Home city:
*
Home state:
*
Select State
AK
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AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
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MI
MN
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MT
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NJ
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Home zip code:
*
Place of employment:
Job title:
Business street address:
Business city:
Business state:
Select State
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Business zip code:
Education and work experience:
*
Special interests, talents and/or skills:
*
I am a cancer survivor.
I am a caregiver.
When were you or the person you cared for diagnosed with cancer?:
Type of cancer:
Metastasis:
Name of primary cancer physician:
Type of cancer treatment:
If chemo, what have you taken?:
If surgery, what type?:
Radiation:
Yes
No
Other treatment?:
Currently under treatment:
Yes
No
If yes, what kind?:
Reason for volunteering (in brief):
Your congregation's name/address (if applicable):
Pastor/Rabbi:
Pastor/Rabbi phone:
Click here to print form
A training fee of $25 per person or $40 per couple is set by our Board to cover the cost of training materials and refreshments. This fee can be paid at the time of the interview. Scholarships are available for those in need.
Upcoming events and training
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© Copyright 2008, CanCare, Inc.
9575 Katy Freeway, Suite 428, Houston, Texas 77024
713.461.0028 or 1.888.461.0028, Fax 713.461.0704
CanCare, Inc. is a nonprofit 501(c)(3) organization.