Volunteer Data & Commitment Form

First name

Last name

Relationship to patient: (Check those which apply)

Patient

Relation

Friend

Not Applicable

OtherOther

Diagnosis/Area of Volunteer Interest/Knowledge: (Check all that apply)

Aplastic anemia

Myelodysplasia

PNH

Other please specifyOther please specify

Year of diagnosis

Age at diagnosis

Address

City

Province

Postal Code

Phone

Fax

Email

How many hours are you available per month

Select the days of the week your available

Please do not call me at the following times

I am available to (check all that apply)

Language Skills ( speak )

Language Skills ( write )

Other personal experiences/medical/psycho-social /technical experience/knowledge which might be helpful to AAMAC’s patients/families/friends

Please note: The Aplastic Anemia and Myelodysplasia Association of Canada has adopted a privacy policy and all volunteers shall be bound by this policy. A copy of the policy is available to you before signing this form.
I agree to be bound by AAMAC’s Privacy Policy. I acknowledge that AAMAC will make every effort to keep personal information, including telephone numbers, diagnoses, etc. confidential.

Signature

Clear

Contact with patients check

If you are interested in having contact with patients, please complete this section.

Please describe your experience. Include treatment, dates of treatment, medications, current status, etc.

Who do you think you would be able to help the most (e.g. parents of young children with aplastic anemia, any patient with MDS, etc.)?

Are you willing to speak to patients from across Canada, just within your province, or just within your city?

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