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About Lamaze

Governance: In-Kind Contributions

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