Mentor / Board Member Application

If you are interested in playing a part at Live for Life, we are always accepting help in any way we can! Being able to play a part in the lives of others is so important. You can play that part!

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Personal Email*
Work Email
Personal Phone*
Work Phone
Professional Background or Affiliation*
You would like to help as a...*
- Board Member
- Mentor
- Fundraiser
- Educator
- Other
(Select all that Apply)
What would you like to contribute as a Board Member?
Any Additional Information
Best Time to Contact You (Please list below)*