DKPH -Volunteer Interest Form

Public Health plays a vital role in providing essential services to our community while advancing health equity.

We encourage volunteers who support the DKPH mission and are committed to protecting, promoting, and improving the health and well-being of all DeKalb County residents. The information provided through this form will remain confidential and help us match you with the most fulfilling and appropriate volunteer opportunity.

Let us know how you would like to contribute to public health at DeKalb Public Health.
Personal Information
Name*

PrefixFirst NameLast Name
Email*
example@example.com
Phone Number*
Emergency Contact
Emergency Contact Name*

PrefixFirst NameLast Name
Emergency Contact Phone Number*
Emergency Contact Relationship*
Educational Background
Select the education level you attained
Do you hold a current clinical license and/or certification? *
Please list your License and/or certification number.
Areas of Interest
NOTE: Please visit SERVICES at DKPH Website for specific information on possible volunteer areas*
In which areas would you like to volunteer?*

Clinical ServiceHealth Assessment and PromotionMaternal & Child HealthVital Records (Birth Certificates & Death Certificates)Environmental HealthOral HealthAdministrationPublic Health PreparednessEpidemiologyQuality Improvement and StrategyCommunications and Media RelationsOther
Type of Provider
Clinical Service: Specialty or Care Area
Helath Assessment and Promotion: Specialty or Care Area
If Other, please specify the Department, Program or Type or Provider:
Why do you wish to be a volunteer in this program? *
Availability Information

Hours of Operation: Monday - Friday 8:15 a.m. - 5:00 p.m.
Select your available days*

MondaysTuesdaysWednesdaysThursdaysFridaysSaturdaysSundays
From*

Hour Minutes

AM/PM Option
To*

Hour Minutes

AM/PM Option
Are you available to volunteer after hours? Example: 4:00pm to 8:00pm*
Are you available to work on weekends?*
NOTE: For Flexible schedules please add additional notes or comments on specific schedules
Please upload your resume and/or any licenses or certifications. *

Cancelof
Please Upload a Letter of Recomendation

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Should be Empty:

Personal Information

Emergency Contact

Educational Background

Areas of Interest

Availability Information