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Vaccination Volunteer Application For Medical Professionals

  1. Vaccination Volunteer Application For Medical Professionals
  2. PLEASE NOTE: All questions in this application REQUIRE an answer. You will not be able to submit this application unless all questions are answered.
  3. Your Contact Information
  4. What is the best time of day to contact you?*
    Check all that may apply.
    1. Your Medical Credentials
    2. What Category Of Medical Credentials Apply To You.*
    3. Do You Have A Current License Or Certification?*
        1. Do You Have Experience In Adminstering Vaccinations?*
            1. Are You Actively Working In The Health Care Field?*
                1. Your Availability
                2. We Currently Have Two Vaccinaton Sites. At Which Location Would You Prefer To Volunteer?*
                3. Portage Location: Days & Hours This Site Is Open*
                  Please check which days you would be willing to commit to at least a four hour shift. Check all that may apply.
                4. Valparaiso Location: Days & Hours This Site Is Open*
                  Please check which days you would be willing to commit to at least a four hour shift? Check all that may apply.
                5. You are almost done. Just click on Submit or Submit & Print below and you will be directed to a submission confirmation page. If you are NOT redirected, it usually means that you have not answered all questions. Please scroll up and answer any highlighted questions then click on Submit or Submit & Print again.
                6. Leave This Blank: