What is Pertussis?
Volunteer Information Form
Personal Information
First Name
Last Name
Street Address
City
State
Zip Code
Home or Work Phone Number
Mobile Phone Number
Email Address
School District
Place of Employment
Select One
American Red Cross
CERT
Gettysburg Hospital
Hanover Hospital
HealthSouth Rehab
Memorial Hospital
Other WellSpan Facility
Private Physician Practice
WellSpan Medical Group
York Hospital
Other
If other, please specify:
Availibility
Days
Evenings
Weekends
Volunteer Information
It is strongly recommended that all volunteers – clinical and non-clinical – register on the SERVPA website. Have you registered on this website?
Yes
No
In what role are you able to function?
Clinical (Vaccine Administration)
Non-Clinical (Greeter, Registration, Logistical Assistance)
If Clinical, what are your professional qualifications?
Select One
MD/DO
PA-C
CRNP
RN
LPN
EMT-P
MA
Other
If other, please specify:
Please provide your Pennsylvania license, certification or registration number.
Expiration Date?
Basic Life Support (BLS) Certified:
Yes
No
Advanced Cardiac Life Support (ACLS) Certified:
Yes
No
Additional Comments