Neighbors in Health
Sunday, August 1, 2010
Volunteer Registration

United Way of the Wine Country invites you to volunteer at the 5th Annual Neighbors in Health on Sunday, August 1, 2010. United Way is the presenting sponsor and volunteer coordinator. We will be working with Kaiser Permanente and several other community organizations to once again offer free health care screening and prevention education to uninsured and underinsured children of Sonoma County.

For volunteer questions or comments, please contact Christine at United Way by phone at (707) 528-4485 x121 or by email.

DEMOGRAPHICS

First Name: *

Last Name: *

Mailing Address: *

City: *

State: *

Zip: *

Day Phone: *

Evening Phone:

Cell Phone:

Email: *

Employer: *

Current Job Title: *

Languages spoken other than English:

T-shirt size: *

*The t-shirts will be the same as last year. If possible, we would appreciate it if you could wear it again this year. **Lunch and light breakfast will be served.

LICENSURE/CERTIFICATION

Do you have a clinical license or certificate?:

If Yes, what:

Expiration Date:

Do you have an active license/certificate on file at Kaiser Permanente?:

*If No, please fax a copy of your license to 707-528-2930.

COMMUNITY PARTNERS

I work for the following NIH community partner organization:

and I have been assigned to the following Healthy Living education area:

Community Partners, please skip ahead to submit volunteer registration.

PREFERRED SHIFT

Exact times will be confirmed a few weeks prior to event.

Saturday, July 31 Set-up:

Sunday, August 1 Volunteer Opportunities:

TYPES OF POSITIONS

Your assigned placement will be based on area of need; however, we will attempt to honor desired request. Please select a position from one of the following areas.

Clinical:

General:

Healthy Living Education Area:

This area is outside and involves general help at interactive and educational booths.

VOLUNTEER AGREEMENT

Age: *

I am 18 years old or older.

I am under 18 years old.

Volunteer Agreement Understanding: *

I am at least 18 years old and have read and agree, of my own free will, to the volunteer agreement (www.unitedwaywinecountry.org/nihagreement). I am aware that this is a release of liability and a contract between myself and United Way of the Wine Country, Kaiser Permanente and/or their affiliate organizations.

As a parent/guardian of a minor between 14-17 years old, I have read the volunteer agreement (www.unitedwaywinecountry.org/nihagreement) and am aware that this is a release of liability and a contract between my child and United Way of the Wine Country, Kaiser Permanente and/or their affiliate organizations.

Neighbors in Health Volunteer Form

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Sunday, August 1, 2010
Volunteer Registration

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Neighbors in Health
Sunday, August 1, 2010
Volunteer Registration