HCHC Vaccination Clinic Volunteer Sign Up Form
Thank you for your interest in volunteering at Hilltown Community Health Center's COVID-19 Vaccination Clinic!

Please fill out the form below, and we will be in touch about required documentation, roles and responsibilities, and schedules.

Thank you!
The HCHC Vaccination Team

**Please be aware, we may not be able to use everyone who volunteers. We will have to staff
the clinic based on demand, availability, and training. We will be in touch with potential volunteers after receiving this form. There are additional forms that will need to be completed before volunteering.
Name *
Mailing Address *
Email Address *
Best telephone number *
Interests/Abilities *
Required
Please list any degrees/experience that we should know about (MD, PA, NP, RN, MA,etc)*
If you are a health care worker, do you have a license?
Clear selection
If so, please enter your license number.
Are you able to speak any other languages and if so, please list.
Is your CPR certification up to date?
Clear selection
Availability to volunteer- 3-4 hours shifts (primarily on your feet)
Mornings
Afternoons
Evenings
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Clear selection
Have you been vaccinated for COVID-19
Clear selection
Documentation Requirements
If we contact you for a volunteer oppurtunity after receiving this form, there are other forms that will need to be completed and signed. In order HCHC requires that all volunteers complete and sign the following forms: Acknowledgement of liability protections, a Criminal Offender Record Information (CORI) request, Confidentiality, Sexual Harassment, Code of Conduct, and HIPAA protections. If you are volunteering to be a clinical volunteer (ie, a vaccinator), there will be additional credentialing and privileging requirements.
Thank you!
We appreciate your interest in learning more about volunteering for HCHC's vaccination clinic. Together, we can all make our communities safer!
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