VOL General Volunteer Application*

Note from our Founder and President Jeanine Patten-Coble

I am excited that you are interested in serving with Little Pink Houses of Hope! Believe me when I say that it can change your life while changing the lives of others. My hope is that your gifts and talents will be utilized in your service with Little Pink and that you will feel at home within our organization. There is no task too small that does not make a huge impact within our organization.

Little Pink Overview

Little Pink Houses of Hope was founded with one simple mission - put a loving embrace around families that are on the physically, emotionally, and financially exhausting breast cancer journey. Our mission is fulfilled by providing free week-long vacation retreats for breast cancer patients and their families. Retreats occur all across the United States allowing the organization to have a national impact while providing personal connections for participants. The once in a lifetime retreat experience is only possible because of a large network of important volunteers. Whether serving at local fundraising events or as retreat volunteers, LP volunteers leverage their gifts and talents to provide a week of joy and hope for our families.

Little Pink Volunteer Mission Statement

At the heart of Little Pink Houses of Hope's volunteer mission is love, love that gives hope to breast cancer survivors and their families through retreats and community events. Communities, Property donors, and Volunteers come together to make the mission come alive, all serving with one purpose - HOPE!

We want you to SERVE!

SERVE with a smile because we have a story to tell of lives that are changed by hope and love.

ENGAGE and be present in the moment to meet the needs of the group and prioritize relationship building over all else.

RELATIONSHIPS are at the heart of Little Pink Houses of Hope. We foster loving relationships by our words, actions, and service,

VALUE each person: vendors, participants, community members, and other volunteers. This is the key to our service model.

ENGAGE - Little Pink strives to make an extraordinary moment in every interaction-phone calls, events, retreats, and chance meetings.

Contact Info

First Name

Last Name

Country

Address 1

Address 2

Postal Code

City

State/Province

Phone Number

Email Address

Yes, I would like to receive email communications.Yes, I would like to receive email communications.

Occupation & Employer

Gender

Ethnicity

Date of Birth

T-Shirt Size (unisex)

Emergency Contact Information

Emergency Contact Name (First, Last Name)

Emergency Contact Address

Emergency Contact City

Emergency Contact State

Emergency Contact Zip

Emergency Contact Relation

Emergency Contact Phone

Emergency Contact Email

Waivers

ASSUMPTION OF RISK ~ I hereby acknowledge the activities associated with any recreational program or volunteer duty may involve an element of risk of injury. Little Pink Houses of Hope does not own, operate, or control the facilities where life enrichment activities are conducted. Consequently, the below signed hereby acknowledges that he/she does hereby assume risk of any injury, illness, harm or damage of any type that may occur during his/her own personal or his/her participation in any Little Pink House of Hope program or event and release Little Pink Houses of Hope and its Board, Officers, Venue, Staff, and Volunteers from any liability or responsibility whatsoever.

MEDICAL TREATMENT ~ I give permission to the medical personnel selected by the program director to order x-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange related transportation for myself or child due to injury, illness, or medical emergency. In the event that I cannot or any other appointed individual cannot be reached in an emergency, I hereby give permission to the physician selected by the program director to secure and administer treatment, including hospitalization, for the above named individual.I agree to the Assumption of Risk & Medical Treatment terms of the above Liability Statements

PERMISSION OF MEDIA USE ~ I grant permission for the above named to participate in any audio-visual, photo, interview, or multi-media event that may take place by Little Pink Houses of Hope and I (we) release everyone involved from liability or claims in association with said coverage. MEDIA RELEASE I grant permission for any photos, audio-visual footage, interviews both recorded and printed of the above named individual, to be used for publication in any multi-media or advertising format, such as brochures, websites, television, public service announcements, ads and publications with the express purpose of marketing and promoting Little Pink Houses of Hope. SOCIAL MEDIA RELEASE I grant permission for any photos, audio-visual footage, interviews both recorded and printed of the named individual, to be shared on social media by Little Pink representatives or by other retreat participants.YesNo

LICENSED DRIVER VERIFICATION ~ Little Pink Houses of Hope is insured as a secondary insurance company to the vehicle owner's primary policy. While acting as a Little Pink Volunteer, this policy is designed to protect both the volunteer and Little Pink Houses of Hope. Failure to abide by any of the below statements relinquishes Little Pink Houses of Hope from all damage and liability claims.

* I agree to enforce the requirement that all passengers wear a seat belt * I agree not to let any elementary school students ride in the front seat of the car with passenger side airbags * I agree to abide by all laws of the state in which I am driving a vehicle as a LP representative

I agree to comply with above statementsYesNot a Licensed Driver

If you are a licensed driver, Please enter the state and license number of your valid driver's license.

CONCEALED WEAPONS POLICY ~ Little Pink Houses of Hope employees, volunteers or participants may not, at any time while on any property owned, leased or controlled by Little Pink Houses of Hope, including anywhere that a company business or activities are conducted, such as property locations, client locations, activity locations, restaurants, company event venues, and so forth, possess or use any weapon.

Weapons include, but are not limited to, guns, knives or swords with blades over four inches in length, explosives, and any chemical whose purpose is to cause harm to another person.

Regardless of whether an employee or participant possesses a concealed weapon permit (CCW) or is allowed by law to possess a weapon, weapons are prohibited on any company property or at any company event or activity. They are also banned in any location in which the employee represents the company for business purposes, including those listed above. A license to carry the weapon on company property does not supersede company policy.

I agree to comply with the Concealed Weapons Policy.Yes

CONFIDENTIALITY AGREEMENT ~ This organization requires that strict confidentiality be maintained with respect to all information obtained by volunteers concerning the organization, as well as the clients and others they serve. The volunteer shall not disclose any information obtained during his/her volunteer placement to any third parties without prior written consent from the organization. Strict guidelines of confidentiality must be maintained regarding all medical information to which a volunteer is exposed. Strict guidelines of confidentiality must be maintained regarding the organization as well. This includes but is not limited to information pertaining to financial status and operations such as budget information, donations of money or gifts in kind, salary information and data pertaining to clients, staff or other volunteers.

No information concerning any volunteer will be divulged without prior written consent of the volunteer. This includes addresses, telephone numbers, background check information, etc. Failure to comply with the confidentially policies of the organization may result in disciplinary actions, including the dismissal of the volunteer.I understand the above and agree to uphold the confidentiality of these matters both during and following my volunteer service with the organization.

Background & Reference Check

I understand and give consent to have a background and reference check done.Yes

Reference Name

Reference Phone

Confirmation

By checking the box provided and printing my name below, I affirm that the facts set forth in this application are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal. I also understand that I may be subject to a background check. It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.

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