volunteer

Medical Personnel Volunteer Form

First Name: * Required
Last Name: * Required
Employer/School:
Assistant to Doctor:
Mailing Address: * Required
City: * Required
State: * 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/WeightYes   No
Blood PressuresYes   No
TranslatorYes   No
Doctor RegistrationYes   No
Direct KidsYes   No
Other (please specify)
ARE YOU A:
Medical Student
RN
Student Nurse
MA
NONE OF THE ABOVE
What is your T-Shirt size?
Comments:
  NOTE: When volunteering a valid photo id will be required.