Coronavirus (COVID-19) Volunteer Sign-up

The Kiowa County Hospital District is looking for volunteers! As we prepare for the possible surge of coronavirus (COVID-19) patients in Kiowa County, we are compiling a list of volunteers (in any capacity) that we may utilize if needed.

If you live in the area and are willing to volunteer if the need arises, please fill in your information below so we can contact you.

Thank you!

Question Title

* 1. Contact Information

Name *

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number *

Question Title

* 2. How do you prefer to be contacted?

Call

Text

Email

Mail

Question Title

* 3. Do you have any experience in healthcare/medical?

Yes

No

Question Title

* 4. If YES to question 2, please describe your experience

Question Title

* 5. Do you have any licenses/certifications?

Yes

No

Question Title

* 6. If YES to question 4, please list your licenses/certifications

Question Title

* 7. Any applicable skills?

Question Title

* 8. What particular area do you wish to volunteer?

Question Title

* 9. Please list days/times of the week you may be available

Question Title

* 10. Do you have any questions or comments?