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* 1. Name

2. Have you ever donated time to a community wellness event, a health care initiative or human service project?

3. Would you share your volunteerism with the Hospital and the community?

4. Please describe the type of service completed?

5. Where was the service provided?

6. Description of Tasks:

7. Can you estimate the time you spent on this effort?

8. How many of your family, associates or friends helped you with your efforts?

9. Can you estimate the time spent by your family, friends and associates on this effort?