Leukemia & Lymphoma Society Patient Access Volunteer Application
Please answer questions as accurately as possible.
Address Line 1
Address Line 2
Phone Number with Area Code
Secondary Phone (if applicable)
Secondary Phone Type:
Date of Birth (format MM/DD/YYYY)
Primary language spoken:
Other languages spoken:
I am available (check all that apply):
1 - 5 hours per week
6 - 10 hours per week
11 - 20 hours per week
20 + hours per week
Why are you interested in volunteering with LLS?
The following section will help determine what volunteer roles would be the best fit for you and LLS. Please check the skills or tasks that you have experience in or would be interested in helping with:
Administrative skills (copying, scanning, sorting, mailings)
Dropping off materials to local treatment centers
Experience with Salesforce
Meeting with healthcare professionals
Microsoft Office proficiency
Public speaking to large groups
Public speaking to small groups
Recognition and appreciation activities
Representing LLS at health fairs
Talking on the phone to patients and family members
Written communication (writing, editing, etc.)
Some Patient Access volunteer roles will require a background check. If required, will you agree to provide the necessary personal information to complete the background check?
Honored Hero: An Honored Hero is a dedicated individual or family who serves as inspiration and provides support to The Leukemia & Lymphoma Society in a variety of ways. An Honored Hero is anyone who has been affected by a blood cancer. As an Honored Hero/Family your story of strength and courage will be shared with participants and donors to provide motivation and encouragement to their money-raising efforts.
I would like more information
LLS relies on fundraising campaigns to support our mission activities. Are you interested in finding out more about fundraising opportunities or volunteering at our fundraising events?
I am interested in more information about volunteering and/or fundraising for:
Light the Night: Every fall, friends, families, and co-workers form fundraising walk teams to participate in an inspirational and memorable evening. Walkers carry illuminated lanterns on a 1 - 2 mile walk.
Man & Woman of the Year: A spirited fundraising competition in which participants build fundraising teams to compete for the title of Man or Woman of the Year. This ten-week campaign culminates in a grand finale in which the man and woman in each community who raises the most funds are named Man and Woman of the Year.
Student of the Year: High school students participate in a six-week fundraising competition to benefit The Leukemia & Lymphoma Society. Candidates raise money in honor of a teen patient hero who is currently battling or is in remission from a blood cancer. The candidate who raises the most money at the end of the six weeks is named the Student of the Year.
Team in Training: The flagship fundraising program for LLS and the only endurance sports training program for charity that raises money for blood cancer research. Our coaches will train you to cross the finish line at a marathon, half marathon, cycling event, triathlon or hike adventure.
Student Series: A service learning, character education and philanthropy program where students gain the unique experience of helping thousands of children and adults in their fight against blood cancers like leukemia. The core program consists of collecting money over a three-week period.
Other campaign events that may be available in your chapter.
I am a:
Caregiver - Parent of child patient
Caregiver - Spouse/Partner of patient
Caregiver - Adult child of parent patient
Caregiver - Sibling of patient
Caregiver - other
Disease Category (if patient):
AML - Acute Myeloid Leukemia
ALL - Acute Lymphoblastic Leukemia
CML - Chronic Myeloid Leukemia
CLL - Chronic Lymphocytic Leukemia
MDS - Myelodysplastic Syndromes
PT - Polycythemia Vera
ET - Essential Thrombocythemia
If Diagnosis is Other, please explain:
Diagnosis Subtype (please type):
Date of Diagnosis - (format 00/00/0000)
Place(s) of Treatment - (hospital/clinic name):
Treatment you received (check all that apply):
Watch and Wait
Allogenic Transplant – Related
Allogenic Transplant – Unrelated
Mini Stem Cell Transplant
Radioimmunotherapy (Zevalin, Bexar)
Monoclonal Antibody Therapy
Clinical Trial (please describe)
Provide details of treatment here including names of drugs:
When did treatment begin (format 00/00/0000)?
When did treatment end (format 00/00/0000)? If treatment is ongoing, type NA.