Application

* Indicates A Required Field

General Information

Name: * Date of Birth:
Address:
City: State:
Zipcode: County:
Email: *
Phone (Work): Phone (Home): *
Place of Employment:

Additional Information

Hobbies, Groups or Activities involved in:

T-Shirt Size:

Volunteer Interests (check all that apply):

Public Speaking Health Fair Displays Office Projects

Media Interviews Delivering Materials BMV Outreach

Workplace Liaison Other

Availability to Volunteer (check all that apply):

Weekdays Evenings Saturdays
Sundays

Any Special Considerations?

The following would best describe me:

Transplant Recipient
Transplant Candidate
Living Donor
Donor Family Member
Other/Believe in Cause

Please comment on how organ and tissue donation has impacted your life:

Optional Selections

Yes, I am willing to have my name, address, phone number, e-mail, and birthday included in the Lifetime of Ohio Volunteer Directory. (Please check box if acceptable, if this box is not marked, we will not include your information in the directory of volunteers given to the other Vital Volunteers.)

Standard Photo Release Form:

Yes, I hereby irrevocably consent to being photographed or being recorded by means of video or audio tape recording by Lifeline of Ohio Organ Procurement, or a designated representative of the organ procurement organization.

These photographs and/or recordings can be used, without compensation to me, in any public display, publication, website, or media, or in any manner or form, and at any time by Lifeline of Ohio Organ Procurement in promotion of the mission to increase organ and tissue donation.

I hereby release Lifeline of Ohio Organ Procurement, its employees, associates, Board of Trustee members, and consultants from any liability in connection with the use of aforesaid materials.

(You are not not required to sign this release form, but it is an option as a volunteer.)