Public Health Volunteer Application Form

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Public Health Volunteer Application

Contact Information

First Name:	*	Last Name:	*
Street Address:	*	Primary Phone:
City:	*	Secondary Phone:
State:	*	Zip:	*
Pager:		Occupation:	*
Primary Email:	*	Secondary Email:

Experience

Please indicate if you have professional or volunteer experience in one of the following areas:

Military	HealthCare	SocialWork
Law Enforcement	Information Technology	Volunteer Coordination
Security	Radio Operation	Accounting
Language Interpretation : Language(s)

Credentials

Please indicate if you are currently licensed in one of following professions:

Physician/Nurse	Optometrist/Ophthalmologist	Veterinarian/Vet tech
Counselor/Social worker	Physical therapist	Dentist/Dental Hygienist
Chiropractor	Occupational/Vocationaltherapist	Psychologist/Psychiatrist

Others (List)

License No :

Experience (yrs)

Terms & Conditions

Due to the nature and content of the Strategic National Stockpile and the potential duties of volunteers, a background check may be conducted on volunteer applications. I understand that a felony conviction for D.W.I., drug-related, sexual or family violence offenses will disqualify me for participation as a volunteer in the SNS program, and that I may be disqualified for other reasons at the discretion of the Public Health Preparedness Division of the Montgomery County Health Department.

Agreement

I have read and understand the above listed requirements, responsibilities and information. I attest to the accuracy of the information I have provided on this application.

Please check to agree

Create Password

Passwords must include at least 6 characters and should contain AT LEAST TWO NUMBERS

Enter password :
Confirm password :		To update your profile, log in with your Primary Email Address