Ambassador Acknowledgements The below acknowledgments are to be completed on an annual basis. If you have any questions, please reach out to the Associate Director of External Communications. Step 1 of 6 16% Ambassador InformationName(Required) First Last Relationship to Lymphoma(Required)Patient/SurvivorCaregiverLymphoma Subtype(Required)Adult T-Cell Leukemia/LymphomaAnaplastic Large Cell LymphomaAngioimmunoblastic T-Cell LymphomaBurkitt LymphomaCentral Nervous System LymphomaChronic Lymphocytic Leukemia and Small Lymphocytic LymphomaCutaneous LymphomaDiffuse Large B-Cell LymphomaFollicular LymphomaHodgkin LymphomaMantle Cell LymphomaMarginal Zone LymphomaPeripheral T-Cell Lymphoma NOSWaldenstrom MacroglobulinemiaN/AEmail Address(Required) Enter Email Confirm Email Phone Number(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Ambassador Handbook AcknowledgementThis Ambassador Handbook is an important document intended to help Ambassadors become acquainted with Lymphoma Research Foundation and the Ambassador Program. This document is intended to provide guidelines and general descriptions only; it is not the final word in all cases. Individual circumstances may call for individual attention. Because the Foundation’s operations may change, the contents of this Handbook may be changed at any time, with or without notice, in an individual case or generally, at the sole discretion of management. Please review the handbook, read the following statements, and sign below to indicate your receipt and acknowledgment of this Handbook.Ambassador HandbookHandbook 1(Required) I have received and read a copy of Lymphoma Research Foundation’s Ambassador Handbook. I understand that the policies, rules and benefits described in it are subject to change at the sole discretion of the Foundation at any time. Date Acknowledged(Required) MM slash DD slash YYYY Code of Conduct AcknowledgementAll Ambassadors will be required to acknowledge the Code of Conduct at the beginning of their term, and on an annual basis. Please read the Code of Conduct policy and acknowledge below. Code of Conduct PolicyCode of Conduct(Required) I have read and agree to abide by the Lymphoma Research Foundation Ambassador Program Code of Conduct. Date Acknowledged(Required) MM slash DD slash YYYY Conflict of Interest AcknowledgementAll Ambassadors of the Lymphoma Research Foundation are asked to review the attached Conflict of Interest Policy (COI) on an annual basis and complete this COI Disclosure Form. If circumstances change and you need to update this form before next year, please contact the Associate Director of External Communications directly.Conflict of Interest PolicyConflict of Interest(Required) I have read the Lymphoma Research Foundation Conflict of Interest Policy and have answered the questions set forth below to inform the agency of potential conflicts of interest created by my own activities and interests. Do you currently hold any position as an ambassador, employee, officer, director, trustee, partner, or joint venture with any other charitable or business entity?(Required)Please Select OneYesNoIf yes, please explain:(Required)Do you or any members of your family have a personal relationship or interest, as defined in the Lymphoma Research Foundation Conflict of Interest Policy? Please refer to examples below.(Required)Examples: Ownership of capital stock, partnerships, or other proprietary rights; Ownership of notes, bonds, or other claims as a creditor; or A direct or indirect beneficial interest through a trust, nominee, or other relationship, including employment of: An entity or enterprise which sells goods or services to the Lymphoma Research Foundation in amounts exceeding $5,000; An entity or enterprise in which assets of the Lymphoma Research Foundation are deposited or invested; or An entity or enterprise which has sought or is seeking any other business connection with the Lymphoma Research Foundation. Please Select OneYesNoIf yes, please explain:(Required)Do you know of any other situations that should be disclosed in light of the principles contained in the Lymphoma Research Foundation Conflict of Interest Policy?(Required)Please Select OneYesNoIf yes, please explain:(Required)Date Acknowledged(Required) MM slash DD slash YYYY Media Consent FormAll Ambassadors will be required to acknowledge the Media Consent Form at the beginning of their term. Please read the Media Consent Form and acknowledge below. Media Consent FormMedia Consent I represent that I am at least 18 years of age, have read and understand the foregoing statement. Date Acknowledged(Required) MM slash DD slash YYYY Travel WaiverAll Ambassadors will be required to acknowledge the Travel Waiver at the beginning of their term. Please read the Travel Waiver and acknowledge below. Travel WaiverMedia Consent I have read and agree to abide by the Lymphoma Research Foundation Travel Waiver. Date Acknowledged(Required) MM slash DD slash YYYY
