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Physician Volunteer Registration Form
First Name:
* Required
Last Name:
* Required
MI:
Degree:
Speciality:
Clinic Name:
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
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:
Physicals
Yes
No
Ear Exams
Yes
No
Ht/Wts
Yes
No
Blood Pressures
Yes
No
Non-medical help
Yes
No
Vision Screening
Yes
No
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.