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Become a Witness Project Volunteer
Please complete the information below and our Training Manager will be in contact with you!
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* Indicates required question
Name
*
Your answer
Complete Address
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Are you a U.S. Citizen
*
Yes
No
If no to the previous question, what is your nationality?
Your answer
Phone Number
Your answer
Are you employed?
Yes
No
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Years of School Completed?
Choose
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
16+
Have you ever worked as an instructor of some kind ( public school, Sunday school, etc), not necessarily for pay?
Yes
No
Clear selection
Have you ever done any public speaking (talked before groups of people formally or informally)
*
Yes
No
Are you comfortable with and do you enjoy talking in front of groups of people?
*
Yes
No
Are you able and willing to participate in 3 to 12 cancer education programs in area (county) per year?
Yes
No
Clear selection
Are you able to attend a total of 8 hours of training?
Yes
No
Clear selection
Since the training will probably take place during the evening hours or weekends, do you have preference?
Morning
Afternoons
Evening
Monday
Tuesday
Wednesday
Thursday
Saturday
Morning
Afternoons
Evening
Monday
Tuesday
Wednesday
Thursday
Saturday
Are you mobile and able to travel away from your home without any assistance?
Yes
No
Other:
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Do you have any child-care or older adult-care responsibilities?
Yes
No
Clear selection
If yes to the previous question, will you be able to make arrangements for those under your care during the time you spend away from home attending training and education sessions?
Yes
No
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If selected to serve as a Lay Health Advisor, I understand I will be required to attend an 8-hour training and commit to observing 3 Witness Project programs before participating in at least 3 additional programs per year. I understand that participants at Witness Project programs may share information regarding their health that may be considered confidential. I agree to not share this information with anyone without their expressed consent.
Yes, I agree
No, I disagree
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