Get Involved

Name*

First Last

Phone

Email*

Date of Birth (Optional)*

Address*

Street Address Address Line 2 City State ZIP Code

County*

Best way to contact me is:

E-mail
Text Message
Facebook

Facebook Name

Occupation

Employer

High School / College / University

Your Relationship to Organ Donation*

I am a member of a donor family
I am a recipient
I am a member of a recipient family
I am a living donor
I am waiting for an organ transplant
I am an advocate for organ and tissue donation
Other

My relationship to donor:

Donor's Name

Date of Donation

Type of Transplant:

Date of Transplant

Name of Transplant(s) Hospital:

My relationship to the recipient:

Recipient's name:

Type of transplant:

Date:

Type of donation:

Given to:

Date:

Type:

Length of wait:

How did you hear about the Donate Life Ambassadors Program?*

When are you able to volunteer?*

Weekdays
Evenings
Weekends
Anytime

Areas of Interests

Public Speaking

Medical / nursing groups
Visit nursing units with KODA
Public / civic groups
Radio / TV / newspaper

Office Assistance

Stuffing envelopes, copying
Computer / data entry
Computer / desktop publishing
Visit Circuit Clerks’ office

Community Outreach

Hosting fundraisers
Social media outreach
Public events (parades and festivals)
“Life is Cool” program

Are you interest in participating in speaking engagements?*

Yes
No

If yes, what size audience do you prefer

Less than 50
50-100 people
More than 100
Any size

If yes, what type of audience do you prefer

Elementary School Students
High School Students
Church Groups
Public / Civic Groups
Any

Are you willing / able to work outdoor events:*

Yes
No

If you have other volunteer experience please describe below:

Please indicate in which of the following areas you might be able to share your expertise:

Ambassador Emergency Information

Ambassador's Name

First Last

In case of an emergency, please notify:

Cell Phone

Home Phone

Work Phone

Address

Street Address City State ZIP Code

Do you consent to being interviewed by media?*

Yes
No

Liability Waiver*

By clicking “I Agree”, I hereby release, waive and forever discharge any and all liability, claims, and demands of whatever kind or nature against Donate Life Kentucky Trust, and its affiliated partners and sponsors, including in each case, without limitation, their directors, officers, employees, volunteers, and agents (the “released parties”), either in law or in equity, to the fullest extent permissible by law, including but not limited to damages or losses caused by the negligence, fault or conduct of any kind on the part of the released parties, including but not limited to death, bodily injury, illness, economic loss or out of pocket expenses, or loss or damage to property, which I, my heirs, assignees, next of kin and/or legally appointed or designated representatives, may have or which may hereinafter accrue on my behalf, which arise or may hereafter arise from my participation with the activity.

I agree

Volunteer

Areas of Interests

Ambassador Emergency Information

Board & Committee Service

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