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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Specialty
*
MD/DO
MA
EMT
RN
CNA
PA
AEMT
OD
PT
PH/PharmD
Pharm Tech
Phlebotomist
MPH
NP
Student
RadTech
DDS/DMD
Retired Health Care Provider
Other:
Required
Phone number
*
Your answer
Email
*
Your answer
Address 1
Your answer
Address 2
Your answer
City
Your answer
County
Your answer
Zip
Your answer
Are you associated with a partner organization?
American Red Cross
HOSA
Roseman University
University of Utah School of Nursing
Eaglegate College of Nursing
Salt Lake Community College of Nursing
Ameritech College of Nursing
Fordis College of Nursing
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Why do you want to volunteer?
*
Your answer
How are you interested in helping?
*
COVID vaccinations
Quarantine and Isolation
COVID testing
General emergency response
Other:
Required
Are you a retired health care provider?
*
If your medical license is less than 10 years expired, you can still help in case of a public health emergency. You will need to fill out:
Yes, retired
No, my license is current
Do you speak any other languages?
If yes, please specify the language below
Your answer
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