COVID-19 Vaccination Clinic Volunteer Application Form

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* 1. Name

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* 2. Contact Information

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 3. Were you referred to the Cumberland County Public Health Department by anyone?

Yes, by an employee

Yes, by a family member or friend

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* 4. Have you ever worked for Cumberland County Government?

Yes

Volunteer or intern

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* 5. When are you available to volunteer (select all that apply)?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

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* 6. Times available to volunteer (select all that apply)

Monday-Friday, 8 a.m. to 5 p.m.

Saturday-Sunday, 8 a.m. to 5 p.m.

Monday-Friday, 5 p.m. to 8 p.m.

Saturday-Sunday, 8 a.m. to 5 p.m.

List any other time periods you are available

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* 7. Please check the highest level of education completed

High School or GED

College or University

Technical Business or Professional School

Graduate School

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* 8. Major field of Study

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* 9. Current or most recent employer

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* 10. Position Held

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* 11. Employment period

Start Date

End Date

Supervisor

Duties

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* 12. I am interested in volunteering for (vaccinating, traffic control, data entry, call center)

copy of current license or certification required to perform vaccinations

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* 13. Job Related Skills

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* 14. Do you speak Spanish?

Yes, fluent

Yes, conversational

Yes, read and write

I speak another language (use box below to enter language)

Thank you for your interest in volunteering. We will review your information to determine how we can use your support. After a placement has been designated, you will be required to complete a background check authorization, information release and confidentiality forms.

COVID-19 Vaccination Clinic Volunteer Application Form

Question Title

* 1. Name

Question Title

* 2. Contact Information

Question Title

* 3. Were you referred to the Cumberland County Public Health Department by anyone?

Question Title

* 4. Have you ever worked for Cumberland County Government?

Question Title

* 5. When are you available to volunteer (select all that apply)?

Question Title

* 6. Times available to volunteer (select all that apply)

Question Title

* 7. Please check the highest level of education completed

Question Title

* 8. Major field of Study

Question Title

* 9. Current or most recent employer

Question Title

* 10. Position Held

Question Title

* 11. Employment period

Question Title

* 12. I am interested in volunteering for (*vaccinating, traffic control, data entry, call center) *copy of current license or certification required to perform vaccinations

Question Title

* 13. Job Related Skills

Question Title

* 14. Do you speak Spanish?

* 12. I am interested in volunteering for (vaccinating, traffic control, data entry, call center)

copy of current license or certification required to perform vaccinations