KEEP Healthy Volunteer Form
The National Kidney Foundation will host 4 upcoming KEEP Healthy Kidney Screenings. We are searching for volunteers.

* Saturday, August 5, 2017 8:00am-12:15pm Centreville City Hall 5800 Bond Ave, Centreville, IL 62207
* Saturday, September 16, 2017 8:00-1:15pm Saints Joachim and Ann Care Services, 4116 McClay Rd, St Charles, MO 63304
* Saturday, October 14, 2017 8:00am-2:15pm Hazelwood East High School 11300 Dunn Rd, St. Louis, MO 63138
* Sunday, October 22, 2017 9:00am-2:15pm St. Cecilia's Catholic Church, 5418 Louisiana Ave. St. Louis, MO 63111

If you are interested in volunteering, please complete this volunteer form. We need both General Volunteers (no special training) and Technical Volunteers (Physicians, Physician Assistants, Nurse Practitioners, RN, LPN, MA, and Registered Dietitians). If you are a technical volunteer please bring a copy of your license with you to the screening.

*The time listed is the entire volunteer time, including training. Please only sign up if you are able to work the entire shift. If you are not able to stay the entire time, please contact Suzanne.McComb@kidney.org in advance to arrange.

KEEP Healthy is the National Kidney Foundation’s (NKF) community-based educational initiative to raise awareness about the kidneys, risk factors for kidney disease, and steps to take to keep kidneys healthy and reduce risk.

To learn more about volunteering with the National Kidney Foundation in Missouri please review our Volunteer Handbook: http://bit.ly/1sXSvGr.

First Name:
Your answer
Last Name:
Your answer
Credentials: (If applicable)
Your answer
Street Address:
Please include apartment and/or suite number if applicable.
Your answer
City:
Your answer
State:
Your answer
Zip Code:
Your answer
Email Address:
Your answer
Phone Number:
Your answer
Date of Birth:
Your answer
Employer/School Affiliation
Please provide the name of company you are employed by or the name of the school you attend. Please feel free to mark N/A if you are unwilling to disclose this information or this does not apply to you.
Your answer
Are you currently a student?
Indicate yes if you are currently enrolled in a college or university or technical training program. If yes, please indicate the type of degree/certificate you are pursuing.
Your answer
Emergency Contact:
Please provide the contacts name, relationship and phone number.
Your answer
Do you speak Spanish?
This program is offered in English and in Spanish.
Are you a Technical or General Volunteer?
A General Volunteer has no required certifications or training. A Technical Volunteer is someone who has current certifications in a healthcare related field. For example, a technical volunteer may be certified to take blood pressure or may be a Medical Doctor or may be a Registered Dietitian, among other certifications. (This is generally indicated by earning credentials after your name)
Which date are you interested in volunteering for?
If you are interested in multiple dates, check all that apply.
Required
Would you be interested in also being a set-up volunteer or clean-up volunteer?
A set-up volunteer arrives 30 minutes before the other volunteers and a clean-up volunteer stays 30 minutes past the end of the screening. Activities include unloading/loading vehicles, setting up/breaking down tables and chairs, setting up/cleaning up screening area. These volunteers will also be expected to stay for the entire screening. This is just a great way to add on additional volunteer hours and helps NKF staff.
Please indicate which KEEP Healthy Stations you are interested in:
Check which volunteer stations you are interested in, you may check more than one. Please note that although we will do our best to place you in your desired area, we may need to utilize you in another similar role for which you are qualified.
Required
By checking I agree, I give permission to be photographed or video recorded by the members and representatives of the National Kidney Foundation. I understand that all photographs and video images will become property of the NKF and that I will receive no compensation. I hereby give permission for all photographs and video images containing my likeness to be used by the NKF for lawful purposes including but not limited to: advertising, marketing, display, publicity, and the NKF newsletter.
I understand that NKF’s KEEP Healthy program is available for use only through the auspices of the NKF Headquarters and NKF Affiliates/Divisions.
I understand that the KEEP Healthy program must be conducted according to the procedures described in the program’s informational materials and by the training provided by the NKF Affiliate/Division.
I understand that confidentiality of all information reported by KEEP Healthy program participants shall not be disclosed to any third party, including a volunteer at a KEEP Healthy Event who does not have a need to know. The only parties to whom any participant information may be disclosed are the National Kidney Foundation or volunteers, who are involved with the KEEP Healthy program and need to be informed of a particular participant situation. I also understand copies of any participant information cannot be retained by me for any purpose except for those related to the KEEP Healthy program. This confidentiality obligation applies even if some or all of the participant information may be available from public sources.
I understand that the KEEP Healthy program and KEEP Healthy materials are protected by copyright, which is owned by the National Kidney Foundation, and no part of the KEEP Healthy Program Manual or materials may be duplicated, distributed, or used for any other purpose other than a KEEP Healthy activity authorized by NKF National Headquarters and NKF Affiliate/Division.
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