FIRST NAME:
LAST NAME:
D.O.B:
SOCIAL SECURITY #
ADDRESS:
CITY:
STATE:
ZIP:
PHONE:
EMAIL:
EMPLOYER:
JOB TITLE:
WORK ADDRESS:
CITY:
STATE:
ZIP:
WORK PHONE:
WORK EMAIL:
JOB DESCRIPTION:
COLLEGE & MAJOR:
GRADUATE STUDIES:
HONORS & AWARDS:
HAVE YOU EVER SERVED ON A CHARITY’S BOARD:
YEARS:
WHICH CHARITY:
ROLE:
WHY DO YOU WANT TO SUPPORT KIDS FIGHT CANCER:
WHAT SKILLS / EXPERIENCE CAN YOU CONTRIBUTE:
WHAT PARTICULAR INTEREST AREAS ARE YOU HOPING TO WORK ON WITH THE BOARD:
ARE YOU CAPABLE OF RAISING A MINIMUM OF $2,500.00 ANNUALLY
DO YOU HAVE RESOURCES TO SOLICIT FOR PRIZES OR OTHER DONATIONS:
DO YOU HAVE ANY PERSONAL FRIENDSHIPS WITH MEMBERS OF THE MEDIA OR CELEBRITIES:
IF SO, WHO:
DO YOU AGREE TO UPHOLD THE MISSION, VALUES AND GOALS OF KIDS FIGHT CANCER:
Verification: