Volunteer Application

Thank you for your interest in the Donate Life Ambassadors program. After completing the form below, your contact information will be added to our database and you will begin receiving information about upcoming events including our one day training workshop held every spring and fall. Once you have attended a training workshop, you will be able to participate in any of our numerous events throughout the year. If you have any questions, please feel free to contact Kathleen Hostert, Community Programs Supervisor at khostert@onelegacy.org or 213-356-5208.

Contact Info

Salutation: Mr. Mrs. Ms. First Name:Last Name:

Address: City: State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip:

Primary Phone: Home Work Mobile Additional Phone: Home Work Mobile

Additional Phone: Home Work Mobile Email: Region: Unknown Bakersfield Inland Empire Los Angeles County East Los Angeles County North Los Angeles County South Los Angeles County West Orange County Santa Barbara/Ventura Out of the Area

Background Info

DOB: JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Ethnicity: Caucasian African American Asian (Burmese) Asian (Chinese) Asian (Filipino) Asian (Japanese) Asian (Korean) Asian (Other) Asian (Taiwanese) Asian (Vietnamese) Indian Latino Native American Persian Other Connection: Donor Family Living Donor Recipient Recipient Relative Transplant Candidate Other

Primary Language: English Burmese Cantonese Mandarin Chinese Japanese Spanish Vietnamese Korean Khmer Italian Tagalog German French Taiwanese Other Secondary Language: English Burmese Cantonese Mandarin Chinese Japanese Spanish Vietnamese Korean Khmer Italian Tagalog German French Taiwanese Other N/A

Hospital/Transplant Center: Organ/s Donated/Transplanted: N/A Heart Liver Lung Kidney Pancreases Small Bowel Tissue Multiple

Donation/Transplant Date: JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Donor: Deceased Living Donor Name, if Known

Recipient: N/A Self Other Recipient Name, if Known Met Donor or Recipient: N/A Yes No No, but we have been in contact

Optional Photo:(jpg, png, or gif)
Ambassador Biography:   Instructions

I have read and agree to the Privacy and Confidentiality Statement
I have read and agree to the Consent Of Use Statement