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Register to be a Covid-19 Vaccination Site Volunteer

2. Register to be a Covid-19 Vaccination Site Volunteer
   Thank you for volunteering to share your time and talents to fight COVID-19. You are making a difference! You may need the following information or documents to complete your application.
4. Clinical License (if applicable)-Criminal Background Check (Results Within Last 2 Years)-Resume-Volunteer Application
6. Name
   Use your legal name, no nicknames
8. First Name*
9. Last Name*
10. Middle Initial
11. Suffix
13. Date of Birth*
    Date of Birth
14. Do you have a valid drivers license?*
    -- Select One --yesno
16. Contact Information
18. Street Address*
19. Apartment, Unit or Suite Number
21. City*
22. State*
23. Zip*
25. Primary Phone*
26. Extension
27. Email Address*
29. EXPERIENCE AND PREFERRED VOLUNTEER ROLES
31. Do you have any special licenses or certifications?
    -- Select One --yesno
33. Do you work in Kendall County*
    -- Select One --yesnorefused to answer/ not applicable
34. How far are you willing to travel to volunteer?*
    -- Select One --1 mile5 miles10 miles15 miles20 miles
36. What are your preferred volunteer roles?*

    (You can select more than one)

    1. Physician
    2. Nurse
    3. Pharmacy Technician
    4. Language Interpreter
    5. Hospitality
    6. Data entry
    7. other
37. Have you had a state and federal criminal background check in the last 2 years?*

    1. Yes
    2. No
39. You Availability *

    1. Monday
    2. Tuesday

    1. Wednesday
    2. Thursday

    1. Friday
    2. Saturday

    1. Sunday
41. Will you help us test our plan by periodically responding to test emails and texts?

    As we wait for the vaccine to arrive, we will be testing our plans to make sure we are as prepared as possible. We will need to test our communication system and the response time of volunteers. You might receive test emails and texts that clearly state they are part of a test.

    1. yes
    2. no
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit Submit and Print

* indicates a required field