State Leader Application

Thank you for your interest in the State Leader program. As a State Leader your experience, skills and talents will make a significant impact in reaching every young woman diagnosed with breast cancer in your state and across the nation. 

Contact Information











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Personal Information
*In order to become a State Leader, you must have at some point been diagnosed with breast cancer.

Format MM/DD/YYYY

Format MM/DD/YYYY





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Volunteer Information



Please indicate if the organization was related to breast cancer.

Provide searchable Facebook Name




Note: you do not need to fill this out if you have already provided YSC with this information on a different form.

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Acknowledgment of Terms & Conditions
By submitting this application, you agree to Young Survival Coalition (YSC) terms and conditions of serving as a YSC State Leader. Please read the following statements and click the appropriate button to verify you have read and agree to these terms.

1. As a YSC State Leader, your contact information will be available on the YSC website.
2. You are a volunteer of YSC and at no time can represent yourself as an employee of YSC.
3. You cannot give medical advice.
4. You cannot use YSC's events to sell products or services.
5. New programs delivered under the YSC logo(s) must be approved by YSC.
6. You cannot sign contracts, open bank accounts, or in any other way act as a legal entity under YSC's name.
7. You have read and agree to the Young Survival Coalition Volunteer Release.
8. You may be dismissed from their role for failure to comply with these terms or at YSC's discretion.