VOLUNTEER FORM

NOMBRE COMPLETO*

PHONE*

EMAIL*

T-SHIRT SIZE

VOLUNTEER:*

I am wanting to volunteer
I am looking to fill required volunteer hours

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

I WOULD PREFER TO VOLUNTEER IN THE FOLLOWING WAYS*

Transportation - Driving patients to and from locations
Fundraising - Organize a fundraiser or drive at your church/workplace/school
Special Skills - Construction, painting, DIY, etc
Special Experiences - I have experiences that I would like to use for volunteering

ARE YOU INTERESTED IN VOLUNTEERING TO DRIVE PATIENTS TO APPOINTMENTS AT SIOUX CENTER HEALTH, OR TO GET MEDICATIONS FROM A PHARMACY OR HOME AFTER AN APPOINTMENT?*

Sí
No

MY AVAILABILITY TO VOLUNTEER IS*

I am willing and able to volunteer most days/times if notified first
I am willing and able to volunteer the following days of the week
I am limited to the certain days/hours listed below
I would have to get back to you with my availability

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?*

Sí
No

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.

LLAME A PROMISE

MÁNDENOS UN CORREO

DIRECCIÓN DE PROMISE