Give Back

The Donate Life Kentucky team educates about the crucial mission of donation and needs action to save more lives. Individuals, communities, and partners, like Kosair Charities, make this possible. 1,000 Kentuckians are currently on the waiting list for lifesaving organ transplants. You can give the gift of life:

8. Thank your county’s Circuit Clerk & Driver’s License Deputies! – County Circuit Clerks

Ambassador Form

Name*
First Last
Phone
Email*
Date of Birth (Optional)*
Month
Day
Year
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:
- Photography
- Videography
- Event Coordination
- Newsletter Publication
- Graphic Design
- Writing
- Church Relations
- Community Networking
- Training / Education
- Fundraising
- Website Design
- Art Design
Volunteer Emergency Information
Volunteer Name
First Last
In case of an emergency, please notify:
Cell Phone
Home Phone
Work Phone
Address
Street Address City State ZIP Code

Request a Speaker

Would you like a speaker for your organization or school? We are happy to help! Please fill out the form below with all the details, and we will follow up with you.