2019 Hear My Voice Application

 

2019 Hear My Voice Outreach Volunteer Program Application

 

Thank you for your interest in the Hear My Voice Outreach Volunteer Program. Living Beyond Breast Cancer (LBBC) is excited to begin recruitment for our Hear My Voice training in Philadelphia, PA from April 5-7. This training will be held in conjunction with the 2019 LBBC Conference on Metastatic Breast Cancer.

If you have already participated in a previous Hear My Voice, Young Advocate or Community Connector training, you cannot apply. We encourage those who have been previously trained to join us for the Conference.

This application will take about 15-20 minutes to complete and will need to be completed in one sitting. Please note that the application requires a personal statement which will ask you why you are interested in the Hear My Voice Program. Information provided on this application will only be shared with the application review team.

You will receive a confirmation email when you have successfully submitted your application. If you have trouble submitting your application, please contact us at hmv@lbbc.org.

  Applicant Information

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Question - Required - Date of birth:




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Question - Not Required - If you had a distant occurrence or recurrence of breast cancer, where did it spread?
Please make up to 7 selections from the choices below.

   


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Question - Required - Did a doctor ever tell you that you had any of the following types of breast cancer?
Please make between 1 and 9 selections from the choices below.

   


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Question - Not Required - What is your racial or ethnic background? Please select one that best represents you.







   


 

(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - Which of the following best describes your current employment or work situation?
Please make between 1 and 8 selections from the choices below.

   


 

To help us ensure economic diversity in our program participants, please share a little bit more information about your household.

If you prefer not to provide this information please type NA in both boxes.

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Question - Required - Which social media platforms do you frequently use?
Please make between 1 and 6 selections from the choices below.

   


 

(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - What LBBC services have you used?
Please make between 1 and 8 selections from the choices below.

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Question - Required - Which of these activities are you interested in doing? Choose your top three of this list.
Please make between 1 and 3 selections from the choices below.

   


 

(Maximum response 255 chars, approx. 5 rows of text)

 

Please answer the following (1-2 short paragraphs per question).

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Hear My Voice Program Terms and Conditions

If you are accepted into the Hear My Voice Program, you will receive financial assistance which includes:

  • 3 nights at the Hilton Penn's Landing in a hotel room shared with another Hear My Voice outreach volunteer. Participants who live more than 20 miles from Philadelphia will receive a room reservation.
  • A fee waiver for the conference fee.
  • A travel reimbursement for up to $450 for your primary form of travel (i.e. plane ticket, bus, train, car mileage, ground transportation) or a free round-trip Southwest plane ticket voucher, if Southwest is available at your airport.

You will be responsible for arranging and paying for your transportation before coming to the conference. You will need to submit receipts and the reimbursement form by May 3, 2019, to be reimbursed by LBBC. You will not be reimbursed for any food or incidentals during your trip. If you are accepted into the Hear My Voice program, LBBC will reserve your hotel room, pay directly for up to three nights and assign you a roommate for the program.

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(Maximum response 255 chars, approx. 5 rows of text)

 

I HAVE READ AND AGREE TO THE FOLLOWING TERMS AND AGREEMENTS OF THE HEAR MY VOICE OUTREACH VOLUNTEER PROGRAM:

  • I understand that should I be accepted into the Hear My Voice Program, I will be asked to complete at least two activities, connect at least one healthcare provider to LBBC, participate in four out of six conference calls, and complete one coaching call with LBBC staff. I will report these activities to LBBC.
  • I understand the eligibility requirements of applying for the Hear My Voice Program
  • I understand the maximum limit for primary travel financial assistance is $450 or a free round-trip plane ticket from Southwest
  • I understand that I am responsible for making travel reservations and making all necessary payments for my own travel
  • I understand the hotel stay will include three hotel nights. LBBC will pay directly for a hotel room shared with another Hear My Voice participant (roommates will be assigned by LBBC)
  • I understand that no funds will be given to me before or during the training for any reason. All funds will be distributed only after receipts are submitted after the training has ended.
  • I understand that in order to receive reimbursement, I must submit receipts with my reimbursement form for all approved travel expenses by May 3, 2019.
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Question - Required - I HAVE READ AND ACCEPT THESE TERMS
Please make 1 selection from the choices below.

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Question - Required - I VERIFY THAT ALL SUBMITTED INFORMATION IS ACCURATE AND VALID.
Please make 1 selection from the choices below.

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