Community Ambassador Program
With National Breast Cancer Foundation

Community Ambassador Application

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Name

*

Email

Primary Phone

What is a good number to reach you? Please include your area code. [(xxx)-xxx-xxxx]

What is your availability for a phone call in the next two weeks?

We want to get to know you better before your training begins!

Mailing Address

Enter an address where we will send you materials and goodies!

A little more about yourself...

Birthdate

*

T-shirt Size

*

How has breast cancer affected you?

Check any that apply

Organization Affiliation/Workplace

Please provide relevant work or volunteer experience.

Skills

Please list at least 3 skills that you possess that will help you serve your community
*

Describe the communities you will be reaching and any specific needs they have.

List specifics such as ethnicity and cultural groups, race, income levels, family structure (one or two-parent household)

Why specifically do you want to serve with NBCF and what are your goals as a Community Ambassador?

*

Terms and Conditions

In consideration of my desire to serve as a volunteer in relief efforts to be conducted by National Breast Cancer Foundation (NBCF), I hereby assume all responsibility for any and all risk of property damage or bodily injury that I may sustain while participating in any voluntary relief effort, disaster exercise or other activity of any nature, including the use of equipment and facilities associated with NBCF.

Further, I, for myself and my heir, executors, administrators and assigns, hereby release, waive and discharge NBCF and its officers, directors, employees, agents and volunteers of and from any and all claims which I or my heirs, administrators and assigns ever may have against any of the above for, on account of, by reason of or arising in connection with such volunteer relief efforts or my participation therein, and hereby waive all such claims, demands and causes of action.

Further, I expressly agree that this release, waiver and indemnity agreement is intended to be as broad and inclusive as permitted by the State of my service, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

I currently have no known mental or physical condition that would impair my capability for full participation as intended or expected of me.

Further, I have carefully read the foregoing release and indemnification and understand the contents thereof and sign this release as my own, free act.

Notice of Filming and Photography

When you enter a National Breast Cancer Foundation (“NBCF”) event or program, you enter an area where photography, audio, and video recording may occur. By entering the event premises, you consent to interview(s), photography, audio recording, video recording and its/their release, publication, exhibition, or reproduction to be used for news, web casts, promotional purposes, telecasts, advertising, inclusion on websites, social media, or any other purpose by NBCF and its affiliates and representatives.

Images, photos and/or videos may be used to promote similar NBCF events in the future, highlight the event and exhibit the capabilities of NBCF. You release NBCF, its officers and employees, and each and all persons involved from any liability connected with the taking, recording, digitizing, or publication and use of interviews, photographs, computer images, video and/or or sound recordings.

By entering the event premises, you waive all rights you may have to any claims for payment or royalties in connection with any use, exhibition, streaming, web casting, televising, or other publication of these materials, regardless of the purpose or sponsoring of such use, exhibiting, broadcasting, web casting, or other publication irrespective of whether a fee for admission or sponsorship is charged. You also waive any right to inspect or approve any photo, video, or audio recording taken by NBCF or the person or entity designated to do so by NBCF. You have been fully informed of your consent, waiver of liability, and release before entering the event.

I hereby certify that I am over the age of 18 years and am competent to contract in my own name or the name of the minor child (volunteer).

Terms and Conditions

We will ask you to submit progress reports/event reports for internal use in addition to various training, certification quiz and updates, and bi-weekly check-ins. Please check below if you agree to meet the expectations of the program.
About National Breast Cancer Foundation
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National Breast Cancer Foundation
2600 Network Blvd, Suite 300
Frisco
TX
United States