Non-Medical Volunteer Application
This application is for volunteers who are not licensed to immunize and are available to help at the Pelham Pharmacy during business hours, Monday to Friday. You must be over 18 to volunteer. We are looking for volunteers who can serve in 4-hour shifts, ideally at least twice a week. Thank you in advance!
Name
*
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Emergency contact person
*
First Name
Last Name
Emergency contact phone number
*
-
Area Code
Phone Number
In which of the following ways are you able to assist:
*
Greeting/Assisting Patients at the Pharmacy
Data Entry
Making Phone Calls
Set-up in the morning (8:00 am)
Clean-up in the evening (6:00 pm)
Recruiting Volunteers
Volunteer Shift Manager
General Tasks
Other
Are you trained to offer CPR? Is your certification up to date?
In addition to English, what languages do you speak?
How how many 4-hour shifts per week (Monday thru Friday) do you have available to serve at the clinic?
*
1
2-3
4-5
Full-time
What weekday hours/days (8:00am to 7:00pm) are you most available?
*
Please indicate if you have any pre-existing conditions, especially any with COVID-19 increased risk?
Have you been vaccinated for COVID-19?
*
We will be building a team at the clinic based on trust, respect, & care. Please help us get to know you by sharing any special skills or resources you have that would be helpful.
Signature (use mouse or track pad to sign)
Submit
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