volunteer

Physician Volunteer Registration Form

First Name: * Required
Last Name: * Required
MI:
Degree:
Speciality:
Clinic Name:
Mailing Address: * Required
City: * Required
State: * Required
Zip: * Required
Day Phone (123-123-1234): * Required
Fax:
Emergency Contact Name:
Emergency Contact Phone:
Email: * Required
Gender:   Female   Male
Approximately how many years have you volunteered for ACT?
Are you bringing an assistant?   Yes   No
(if yes, please be sure he/she completes a volunteer form)
Do you speak conversational Spanish?   Yes   No
Shifts:   7:00am-12:00pm   11:45am-3:30pm   All Day
VOLUNTEERING TO DO:
PhysicalsYes   No
Ear ExamsYes   No
Ht/WtsYes   No
Blood PressuresYes   No
Non-medical helpYes   No
Vision ScreeningYes   No
What is your T-Shirt size?
Comments:
  NOTE: When volunteering a valid photo id will be required.