KEEP Healthy Volunteer Form - KS
The National Kidney Foundation is bringing our community kidney health screening program, KEEP Healthy, to three Kansas locations this year. We are now searching for Medical / Technical / General and Bilingual volunteers!

--- Saturday, August 25, 2018
--- CRC Care Center at Avondale East
--- 455 SE Golf Park Blvd
--- Topeka, KS 66605


KEEP Healthy is the National Kidney Foundation’s (NKF) community-based educational initiative to raise awareness about the kidneys, risk factors for kidney disease, and steps to take to keep kidneys healthy and reduce risk.

Volunteers needed to assist screening participants with filling out paperwork, check participants in, help participants through the process, measure height and weight, take blood pressure and record readings on paperwork. These volunteers must have legible writing and some may have to stand for an extended period of time.

If you are interested in volunteering at this event, please complete this volunteer form. We need both General Volunteers (no special training) and Technical Volunteers who have the following credentials- Physician, Nurse Practitioner, Physician Assistant, Registered Nurse, LPN (preferably 2 + years experience) or a Registered Dietitian.

To learn more about volunteering with the National Kidney Foundation in Kansas and Missouri please review our Volunteer Handbook: http://bit.ly/1Kp9KNE

First Name: *
Your answer
Last Name: *
Your answer
Credentials: (If applicable)
Ex. Nursing Student, MA, RN, Blood Pressure certified, DO, MD, NP, etc.
Your answer
Street Address: *
Please include apartment and/or suite number if applicable.
Your answer
City: *
Your answer
State: *
Your answer
Zip Code: *
Your answer
Email Address: *
Your answer
Phone Number: *
Your answer
Date of Birth:
Your answer
Emergency Contact: *
Please provide the contacts name, relationship and phone number.
Your answer
Employer/School Affiliation *
Please provide the name of company you are employed by or the name of the school you attend. Please feel free to mark N/A if you are unwilling to disclose this information or this does not apply to you.
Your answer
Are you currently a student?
Indicate yes if you are currently enrolled in a college or university or technical training program. If yes, please indicate the type of degree/certificate you are pursuing.
Your answer
How did you hear about our KEEP Healthy event and need for volunteers? *
Your answer
Are you a Technical or General Volunteer?
A General Volunteer has no required certifications or training. A Technical Volunteer is someone who has current certifications in a healthcare related field. For example, a technical volunteer may be certified to take blood pressure or may be a Medical Doctor or may be a Registered Dietitian
Please indicate which KEEP Healthy Stations you are interested in: *
Check ALL volunteer stations you are interested in, you may check more than one. Please note that although we will do our best to place you in your desired area, we may need to utilize you in another similar role for which you are qualified. All volunteer positions are for the duration of the event unless otherwise noted. THOSE VOLUNTEER STATIONS WHICH ARE NOW FULL HAVE BEEN LISTED - FULL. IF YOU CHOOSE THAT STATION, PLEASE NOTE THAT YOU WILL ONLY BE ASSIGNED THERE SHOULD THERE BE ANY CANCELLATIONS. OTHERWISE WE WILL ASSIGN YOU WHERE NEEDED. THANK YOU!
Required
I would be interested in being contacted about assisting with set up for the event - Saturday, August 25th at 8:00 am - 9:00 am *
Required
Please indicate language skills in addition to English. *
Please check only those in which you are able to speak in conversationally or better.
Required
By checking I agree, I give permission to be photographed or video recorded by the members and representatives of the National Kidney Foundation. I understand that all photographs and video images will become property of the NKF and that I will receive no compensation. I hereby give permission for all photographs and video images containing my likeness to be used by the NKF for lawful purposes including but not limited to: advertising, marketing, display, publicity, and the NKF newsletter.
I understand that NKF’s KEEP Healthy program is available for use only through the auspices of the NKF Headquarters and NKF Affiliates/Divisions.
I understand that the KEEP Healthy program must be conducted according to the procedures described in the program’s informational materials and by the training provided by the NKF Affiliate/Division.
I understand that confidentiality of all information reported by KEEP Healthy program participants shall not be disclosed to any third party, including a volunteer at a KEEP Healthy Event who does not have a need to know. The only parties to whom any participant information may be disclosed are the National Kidney Foundation or volunteers, who are involved with the KEEP Healthy program and need to be informed of a particular participant situation. I also understand copies of any participant information cannot be retained by me for any purpose except for those related to the KEEP Healthy program. This confidentiality obligation applies even if some or all of the participant information may be available from public sources.
I understand that the KEEP Healthy program and KEEP Healthy materials are protected by copyright, which is owned by the National Kidney Foundation, and no part of the KEEP Healthy Program Manual or materials may be duplicated, distributed, or used for any other purpose other than a KEEP Healthy activity authorized by NKF National Headquarters and NKF Affiliate/Division.
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