Volunteer Interest Form
Columbia County Public Health
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Specific interests
Vaccinator
Vaccination/Testing site - support roles (greeter, registration, scribe, monitor, supply runner)
Appointment scheduling
Other
Do you currently have an active license, certification or registration as a health professional or allied health professional, or have you had an active license, certification or registration within in the last five years? (Not required for all roles)
*
Please Select
Yes
No
Credential (if applicable)
Please Select
Certified nursing assistant (CNA)
Dentist
Direct entry midwife
Emergency medical services provider (EMT, AEMT, EMT Intermediate or Paramedic)
Naturopathic physician (ND)
Advanced practice registered nurse (APRN)(includes nurse midwives)
Registered nurse (RN)
Licensed practical nurse (LPN)
Optometrist
Pharmacist, pharmacy intern, or pharmacy technician
Phlebotomist
Physician (MDs and DOs)
Physician assistant
Podiatrist
Respiratory therapist
Traditional health worker
Veterinarian
None of above
Are you a healthcare student in one of the following fields of study? (Not required)
Please Select
Dental
Emergency medical services providers (EMT, AEMT, EMT Intermediate or Paramedic)
Medical
Midwifery
Naturopathic medicine
Nursing (including CNA programs)
Optometry
Pharmacy and pharmacy intern
Physician assistant
Podiatry
Respiratory therapy
Veterinary
Can you commit to at least three 5-hour shifts per month?
Please Select
Yes
No
Briefly describe your relevant experience and what volunteer roles interest you.
Please include any other relevant information
Submit
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