ELKHART COUNTY HEALTH DEPARTMENT: VOLUNTEER TO HELP WITH THE HEALTH DEPARTMENT'S COVID-19 VACCINE CLINIC
Please complete this form if you are interested in volunteering with Elkhart County Health Department's COVID-19 vaccine clinic. Must be willing to submit for a background check. We will contact you as the needs arise.
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Full Name
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Your answer
Date of Birth
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MM
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DD
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YYYY
Address
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Your answer
Email (if you do not have one please type N/A)
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Your answer
Phone Number
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Your answer
Available with 24 hour notice?
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Yes
No
Provide Days and Hours of Availability. Schedule is subject to change. Clinic hours are Monday and Wednesday 9:30am-6:00pm; Tuesday, Thursday, and Friday 8:00am-4:00pm; Saturday 7:30am-12:30pm
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Your answer
Are you a healthcare professional?
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No
Clear selection
Professional License Type (eg. RN, MD)
Your answer
Professional License Status
Active
Expired
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Professional License Number and Expiration Date (eg. #xxxx, 1/1/1111)
Your answer
Professional Certifications or Specific Skillset
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Other language abilities (besides English)
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Previous volunteer experience
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