VHPCHC Volunteer Application
This application is for those with an interest in volunteering with Valley Health Partners Community Health Center (VHPCHC). All volunteers must be able to wear a mask covering the nose and mouth at all times to be considered.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Gender
Please Select
Female
Male
I perfer not to answer
Ethnicity
Please Select
American Indian
Asian or Pacific Islander
Black or African American
Hispanic or Latino
Native Hawaiian or other pacific islander
White
I perfer not to answer
Lived in PA the last 10 consecutive years?
Please Select
Yes
No
Veteran
Please Select
Yes
No
Volunteer Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Interest in volunteering
Why do you want to volunteer? Are you volunteering to complete a particular requirement? Example: School Graduation Project, Court Mandated Community, etc. How did you find out about Volunteer Services at VHPCHC
Work/Volunteer/Educational experience
Please tell us a little bit about your work, education and volunteer background. Are you currently employed or are you retired? If employed, where are you employed? Have you volunteered before? If so, where?
Are you an employee of VHPCHC?
Please Select
Yes
No
Have you ever been convicted of a misdemanor or felony?
Please Select
Yes
No
If you have been convicted of a misdemeanor or felony, please explain.
Have you ever had any of the following diseases: Mumps, Rubella, Polio, Measles, Chicken Pox, Tuberculosis?
Please Select
Yes
No
Please list the name of an individual we may contact in case of an emergency.
First Name
Last Name
Emergency contact relationship:
Please Select
Aunt/Uncle
Colleague
Daughter
Friend
Parent
Partner
Sibling
Significant Other
Son
Spouse
Emergency Contact Phone Number:
Please enter a valid phone number.
Comments
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