Your contributions to Lamaze International are truly valued. Please estimate to the best of your ability your contributions, and feel free to write on back or attach a separate page.
Name_________________________________________________ Time Period _______________
1) Contributions of Time
·
Attending meetings __________hours
·
On the phone __________hours
·
Doing work __________hours
·
Other (describe) __________hours
Total __________hours
Amount you are paid for your time for similar work: $ _____________ /hour
Total Hours ________x $________ per hour = $ _____________
2) In-Kind Contributions
·
Copying, printing $ _____________
·
Telephone $ _____________
·
Travel costs $ _____________
·
Other – describe: $ _____________
Total
$ _____________
3) Financial Contributions (beyond membership dues)
Description $ _____________
4) Contributions You Solicited on Behalf of Lamaze International.
Description $ _____________
Do letters of thanks need to be sent to anyone?
5) Please note any other contributions.
Thank You!
Attachment 1
Conflict Of Interest Statement
I have read and understand the Conflict of Interest Policy, and have identified below any potential conflicts of interest which may arise in my capacity as a Lamaze International officer, committee member, consultant or staff person.
Potential conflicts of interest
__________________________Signature
__________________________Date