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Speakers Bureau Interest Form

 

Speakers Bureau Interest Form

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Question - Required - Date




2. Your information:

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Name:

 

 

   

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City/State/ZIP:

 

    

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Date of Birth:

 

 

 


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Question - Required - Which Speakers Bureau activities would you like to participate in? (select all that apply)

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  Komen Volunteer Release
Emergency Contact:
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  I wish to volunteer for Susan G. Komen for the Cure, Greater Nashville Affiliate. I understand that the nature of volunteer activities that I may perform in my capacity as a volunteer may involve physical activity, contact with unidentified or unfamiliar persons, or other potential risk of bodily injury or damage to property. Knowing this, I hereby assume full and complete responsibility for any personal injury and/or property damage that I may sustain or cause during my participation as a volunteer. In addition, I hereby release, hold harmless & covenant not to file suit against the Komen Affiliate, Susan G. Komen for the Cure, Inc. and of their employees, volunteers, partners, agents, Sponsors, Board Members and Successors from any and all loss, liability or claims I may have arising out of my service as a volunteer. I understand that as a volunteer, I may become privy to confidential information about the Komen Affiliate or Susan G. Komen for the Cure. I agree to maintain the confidentiality of any information marked “confidential” as well as any information about the Komen Affiliate’s or Susan G. Komen for the Cure’s internal procedures, business operations, personnel information and the like that is not otherwise publicly disclosed by the Komen Affiliate or Susan G. Komen for the Cure. I will not use any confidential information in any manner that would be detrimental to the Komen Affiliate or Susan G. Komen for the Cure, and I will avoid any actions that might impair the reputation of the Komen Affiliate or Susan G. Komen for the Cure.
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