Medical Volunteer Application
This application is for volunteers who are licensed to immunize
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
Are you a licensed medical professional?
*
Yes
No
What kind of medical license do you have, and is it current? What is your medical license number?
*
What medical positions have you held?, If you are currently working, where do you work? If you are retired, when did you retire?
*
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:
*
Registering Patients at the Pharmacy
Drawing Vaccine (for this option, you are required to complete this CDC training module: https://www2.cdc.gov/vaccines/ed/covid19)
Immunizing Patients
Monitoring Patients post-vaccination
Recruiting Other Volunteers
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 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
Should be Empty: