VOLUNTEER – DRIVING – Promise Community Health Center – Located in Sioux Center, Northwest Iowa

FULL NAME*

ADDRESS*

STREET ADDRESS CITY STATE

PHONE*

EMAIL*

T-SHIRT SIZE

VOLUNTEER:*

HOW MANY HOURS DO YOU NEED TO FILL?

DO YOU BELONG TO AN ORGANIZATION OR ATTEND A CERTAIN SCHOOL?

APPROX. DATE/HOURS NEED TO COMPLETED BY

HOW FAR ARE YOU ABLE AND WILLING TO DRIVE?*

Only in Sioux Center
In Sioux Center and to surrounding cities such as Orange City, Alton, Hull, Boyden, Rock Valley
To speciality appointments as far as Sioux Falls and Sioux City

MY AVAILABILITY TO VOLUNTEER IS*

WHAT DAYS ARE YOU AVAILABLE?*

WHAT HOURS ARE YOU AVAILABLE?*

INDICATE ANY LANGUAGES, OTHER THAN ENGLISH, THAT YOU ARE FLUENT IN FOR SPEAKING, READING OR WRITING.

DO YOU KNOW ANYONE AT PROMISE CHC?*

IF YES, WHO AND WHAT IS YOUR RELATIONSHIP TO THEM?*

HOW DID YOU LEARN ABOUT THIS VOLUNTEER OPPORTUNITY?*

PLEASE SPECIFY WHICH EMPLOYEE, COLLEGE PROFESSOR, ETC REFERRED YOU.

AUTHORIZATION*

Submission of this form is your authorization to be contacted by Promise about upcoming events and volunteer opportunities.

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VOLUNTEER – DRIVING