2019 Medical Volunteer Application
Last Name *
Your answer
First Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
Your answer
Email Address *
Your answer
Do you plan on staying overnight during the days you are volunteering? *
Required
T-shirt Size (unisex) *
How did you hear about us? *
(eg. I have worked at Dragonfly before, Hospital affiliation- CHOP, Social worker- Name, Online database)
Your answer
Do you have any allergies or dietary restrictions? *
Your answer
Current Address
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip/Postal Code *
Your answer
Permanent Address (if different from above) *
Your answer
License Information
Medical Position *
License Number *
Your answer
In what state was your license issued? *
Your answer
What is your hospital affiliation? *
Your answer
Availability Information
What dates are you available to volunteer in summer 2019? *
Required
If you do not plan on staying the whole week, what dates are you available within each session?
Formatting: Session 1- June 26, Session 4- July 16-19
Your answer
If you are staying the night, are you available to be on-call for medical issues during the night? *
Doctor applicants: please select the option below if you are interested in being available for an On-Call shift during the time that you are not in the Poconos.
Eligibility Verification
Dragonfly Forest Immunization Policy *
Many of the children that Dragonfly Forest serves have compromised immune systems congruent with their individual medical condition. In order to best protect our campers from infectious disease, we firmly believe that all children and young adults should receive all of the recommended vaccines according to the schedule published by the Centers for Disease Control and the American Academy of Pediatrics. These include *Diphtheria,Tetanus, and Pertussis (DTaP, DTP, DT, Tdap, or Td)—3 doses *Polio (OPV or IPV)—3 doses *Measles, Mumps, and Rubella (MMR)—1 dose *Varicella (chickenpox)--1 dose or prior case of chickenpox *Pneumococcal--4 doses *HIB-3 doses
Have you ever been accused of harassment of any person including, but not limited to, work place harassment? *
Have you ever been convicted of a crime other than minor traffic offenses? *
If you selected "yes" to either of the above questions, please explain below.
Your answer
I verify that all information in this application is current and accurate to the best of my knowledge. *
Please type your full name as an electronic signature to confirm the above statement.
Your answer
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