about
board & staff
event day
history
galleries
donate
sponsor
volunteer
vendor
contact
volunteer
Medical Personnel Volunteer Form
First Name:
* Required
Last Name:
* Required
Employer/School:
Assistant to Doctor:
Mailing Address:
* Required
City:
* Required
State:
Choose a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
* Required
Zip:
* Required
Contact Phone Number:
* Required
Email:
* Required
Gender:
Female
Male
Do you speak conversational Spanish?
Yes
No
Do you work for HEAD START?
Yes
No
Are you willing to be there at 4:00pm the day before to help set up?
Yes
No
Are you willing to stay until 5:00pm the day of to help clean up?
Yes
No
Have you been recruited for a specific area?
Yes
No if so, which area?
PLEASE INDICATE WHAT AREAS YOU HAVE PREVIOUSLY VOLUNTEERED FOR / ARE QUALIFIED TO DO:
Height/Weight
Yes
No
Blood Pressures
Yes
No
Translator
Yes
No
Doctor Registration
Yes
No
Direct Kids
Yes
No
Other (please specify)
ARE YOU A:
Medical Student
RN
Student Nurse
MA
NONE OF THE ABOVE
What is your T-Shirt size?
Medium
Large
X-Large
XX-Large
XXX-Large
Comments:
NOTE: When volunteering a valid photo id will be required.