Volunteer

First Name *

Last Name *

Email *

Phone *

Address *

City *

State *

Zip Code *

How did you hear about us: *

Friend

Another Volunteer

School

Internet

Media

Other

Are you Florida Licensed Professional? *

Yes

No

If yes, please specify your specialty and years of experience in your field of expertise:

Will you be receiving certification/academic or internship credit? *

Yes

No

If yes, please indicate the program/school/degree and total of hours needed.

Why are you seeking volunteer opportunities? *

Are you able to provide a minimum of 3 months service hours? *

Yes

No

SKILLS AND INTERESTS

What type of volunteer work are you interested in? Please check one or add additional ones

Outreach Event

Translation (Haitian-Creole to English)

Sante Pam TV Show Assistant

Social Media Assistant

Licensed Professional Services

Other:

List any of your special skills/training? *

What is your availability? *

Other than English, do you speak other languages? If yes please indicate language and proficiency.

Language 1:

Able to translate:

Yes

No

Language 2:

Able to translate:

Yes

No

EXPERIENCE

Do you have any previous volunteer experience? *

Yes

No

If yes, please explain when, where and duties performed:

AGREEMENT AND SIGNATURE

By submitting this form, you affirm that the facts set forth in it are true and complete. You also understand that if accepted as a volunteer, any false statements, omissions or other misrepresentations made by you on this form may result in immediate dismissal.

Sygnature / Date

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Volunteer Request Form

SKILLS AND INTERESTS

EXPERIENCE

Our Policy

Our mission is to improve the health of individuals to prevent and manage health conditions through education and promotion of healthy eating and physical activity.

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