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.
Full Name *
Date of Birth *
MM
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DD
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YYYY
Address *
Email (if you do not have one please type N/A) *
Phone Number *
Available with 24 hour notice? *
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 *
Are you a healthcare professional?
Clear selection
Professional License Type (eg. RN, MD)
Professional License Status
Clear selection
Professional License Number and Expiration Date (eg. #xxxx, 1/1/1111)
Professional Certifications or Specific Skillset
Other language abilities (besides English)
Previous volunteer experience
Submit
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