Volunteer Data Form

If you have questions about volunteering,

contact Sheena Williams at (203) 346-3906

Name

Mailing Address

Town

State

Zip Code

Please list any special skills or knowledge(i.e. computer skills, foreign language, etc.)

Day Phone Number

Evening Phone Number

Cell Phone Number

Fax Phone Number

Email Address

Which of the above is the best way to reach you in an emergency?

Choose all that apply

Please note, it is not necessary to have a medical background to volunteer.

Professional health or medical backgroundNot Required

If YES please complete the following

If Other

Professional License Number

Date of Expiration

Please indicate your area of specialty

If applicable

Name of Practice

Address of Practice

Town where practice is located

State where practice is located

Zip Code where practice is located

Are you currently licensed by the State of CT to administer vaccinations?

Yes or No

All information submitted will be kept confidential.

If you have any questions about volunteering please contact Sheena Williams, Emergency Preparedness Coordinator.

Volunteering will require a minimal commitment (less than 4 hours per year) unless an actual emergency event occurs.

If you have friends, family, or co-workers interested in volunteering, please have them visit our website.