Milw CovidSitters Student Intake Form
Thank you for volunteering to support providers during COVID19! Please remember that your participation is entirely voluntary and to take care of yourself during this time too!

PLEASE READ: if you meet any of the following criteria, we are unable to partner with you at this time and we apologize.

-Experienced a fever in the past 2 weeks
-Experienced shortness of breath in the past 2 weeks
-Traveled to Europe, China, South Korea or Iran in the past 2 weeks
-Had contact with anyone diagnosed with COVID-19
-Have not had a background check as part of your current education program
-Are not fully immunized (standard immunizations + current influenza immunization)
-Are not a health profession student of the Medical College of Wisconsin

NOTE: LCME has strict rules and regulations regarding performing "personal tasks" for residents and attendings. Therefore, please bear in mind the following when applying to volunteer with Milwaukee CovidSitters:
-Student participation is completely voluntary.
-All student-provider pairs will be documented and stored for reference.
-Students and providers are encouraged to consider any conflicts of interest and understand that they will not be able to be evaluated by their assigned provider in the future, and will need to request reassignment if necessary.

You can contact us at milwcovidsitters@gmail.com with any questions!
Please provide your .edu email address *
Please provide your full name *
Which program are you enrolled in (MD, Pharm, Masters)? *
Would you be comfortable providing childcare in a home with the animals listed below? Please check if comfortable with that type of animal. *
Required
Which servies do you feel comfortable providing as part of your time serving in a family's home? Please select all that apply. *
Required
If you answered "yes" to tutoring above, please list below subjects you would feel comfortable tutoring in.
Is there a time of day that works best for you? Please check all available times. *
Required
How many hours per day could you assist? Check all that apply. *
Required
How many days per week could you assist? Check all that apply *
Required
Which days of the week are you available? Please check all you are available for, we will keep in mind how many days per week you have noted above. *
Required
Do you have experience working with children? *
If yes, please elaborate - not required but helps us assess capabilities.
Do you feel comfortable supervising children in grades K-8? *
Do you feel comfortable supervising children younger than school age (birth-age 5)? *
How many children would you feel comfortable supervising on your own at one time? Check all that apply. *
Required
Do you have experience supervising children with developmental disabilities? *
If yes, please elaborate.
Do you feel comfortable supervising children with well managed chronic health conditions (eg: asthma, type 1 diabetes)? *
What is your zip code? *
What general region of the Milwaukee area would you be willing to serve?
Do you have a car to get to/from service locations? *
How far are you willing to commute to provide services? *
Would you like to be contacted about other volunteering activities not related to Milwaukee CovidSitters?
Clear selection
Are you currently in Quarantine? If yes, until when? *
Do you have CPR/BLS certification? (NOTE: CPR/BLS certification is a plus, not a requirement). *
PLEASE READ CAREFULLY - Clicking yes constitutes an electronic signature, attesting that you will meet these requirements *
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PLEASE READ CAREFULLY - Clicking yes constitutes an electronic signature, attesting that you have read the following addendum. *
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By checking this box, I am attesting that I have undergone a background check as part of my health professional program and I am up to date on required vaccinations, including the annual influenza vaccine. *
Required
By checking this box, I understand and agree that I am voluntarily acting in my own individual capacity outside of any affiliation I may have with local universities, and I am not expecting compensation for my services provided through this program. *
Required
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