HCHC Vaccination Clinic Volunteer Sign Up Form

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Thank you for your interest in volunteering at Hilltown Community Health Center's COVID-19 Vaccination Clinic!

Please fill out the form below, and we will be in touch about required documentation, roles and responsibilities, and schedules.

Thank you!
The HCHC Vaccination Team

**Please be aware, we may not be able to use everyone who volunteers. We will have to staff
the clinic based on demand, availability, and training. We will be in touch with potential volunteers after receiving this form. There are additional forms that will need to be completed before volunteering.

Name *

Mailing Address *

Email Address *

Best telephone number *

Interests/Abilities *

Medical Professional (able to give and prepare injections)

Greeter (able to help patients complete the vaccination registration form)

Observer (with the vaccinator, stays in the vaccination room, settles patients, reviews registration form, cleans chairs.)

Admin Assistance (phone calls)

Other:

Required

Please list any degrees/experience that we should know about (MD, PA, NP, RN, MA,etc)*

If you are a health care worker, do you have a license?

Yes

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If so, please enter your license number.

Are you able to speak any other languages and if so, please list.

Is your CPR certification up to date?

Yes

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Availability to volunteer- 3-4 hours shifts (primarily on your feet)

Mornings

Afternoons

Evenings

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

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Have you been vaccinated for COVID-19

I am fully vaccinated - My last dose of Moderna or Pfizer, or my one dose of Janssen, was more than two weeks ago

I am partially vaccinated - I have had one dose of Moderna or Pfizer, or my second dose was less than two weeks ago

I am not vaccinated, but would like to be

I am not vaccinated, and do not plan to be vaccinated or cannot be vaccinated.

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Documentation Requirements

If we contact you for a volunteer oppurtunity after receiving this form, there are other forms that will need to be completed and signed. In order HCHC requires that all volunteers complete and sign the following forms: Acknowledgement of liability protections, a Criminal Offender Record Information (CORI) request, Confidentiality, Sexual Harassment, Code of Conduct, and HIPAA protections. If you are volunteering to be a clinical volunteer (ie, a vaccinator), there will be additional credentialing and privileging requirements.

Thank you!

We appreciate your interest in learning more about volunteering for HCHC's vaccination clinic. Together, we can all make our communities safer!

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