TMH VOLUNTEER SERVICES
COMMUNITY VOLUNTEER APPLICATION

TO BE COMPLETED BY APPLICANT:

NAME:

MALE:                                    FEMALE:

ADDRESS:

CITY:

ZIP:

PHONE NUMBER:

SS#:

DOB:

AGE:

HEALTH RECORDS

Describe your health during the past year:
GOOD        OTHER, Explain:
 

Are you currently taking any medication?
NO               YES, Identify:

Do you have a history of serious or chronic illness?
NO                If yes, please explain:

Any known allergies?
Had chicken pox or shingles?

Are the following immunizations up to date?  We would like to have a physician's signature to verify the dates.  If getting the signature is difficult for you, please call your physician's office and get the dates and the name of the person who gave you the information.

MMR: (Measles, Mumps, Rubella)  Date Given:

Tetanus/DT:  Last Date Given:

Hepatitis B:  Dates for all shots (3):

Physician's Signature

______________________________

Physician's Name:

______________________________

WE MUST HAVE ALL HEALTH INFORMATION COMPLETED IN ORDER TO VOLUNTEER.

I hereby agree to serve as an Arts In Medicine Volunteer at Tallahassee Memorial HealthCare and I understand that I will perform, under supervision, only those duties to which they have received instruction.

_________________________________
Signature

______________________________

Date