VOLUNTEER FORM

Please fill out the form below. All fields and sections must be completed/answered before submitting.

Volunteer Info
Name:*
Occupation and/or Student:*
If student, what school/university and what program of study:
Cell Phone or Best Contact Phone Number:*
Email Address:*
Languages Spoken (yes or no) and Translation Capabilities: *
English:
- Yes
- No
Spanish:
- Yes
- No
Creole:
- Yes
- No
T-Shirt Size:*
- S
- M
- L
- XL
- XXL
Emergency Contact Info
Emergency Contact Name:*
Relationship:*
Work Telephone Number:*
Cell Phone Number:*
Volunteer Opportunities Available: *
Diabetes Risk Assessment Screening and Educational Events
- Yes, I would like to help the Diabetes Coalition with Risk Assessment Screenings and and Targeted Community Educational and Outreach Events.
- Preparing screening site packets and “filling goodie bags” to be given to each screening participant during Diabetes Month and at other screening events throughout the year.
- Administering the Diabetes Risk Assessment Screenings, and/or Health Biomarker tests (A1cs) at screening sites and targeted educational outreach events
- Pre-event set-up for Diabetes Awareness Day in early November, which is hosted by the Palm Beach Outlets, in collaboration with the Diabetes Coalition and Palm Healthcare Foundation.
- Diabetes Awareness Day Volunteers – event day set-up, welcoming community partners and participants, diabetes risk assessment screenings.
- Post-event clean-up – after the Diabetes Awareness Day celebration.
- The Data and Resource Committee to collect and enter the Risk Assessment and Health Biomarker Screening Data gathered during the year, which includes November, Diabetes Month.
The Annual Diabetes Educational Symposium
- Yes, I would like to help the Diabetes Coalition with the Annual Diabetes Educational Symposium.
- Pre-preparation activities for the symposium, which include putting materials and individual program packets together.
- Welcoming participants the day of the event – checking in attendees at the registration, making sure that all individuals requesting CME/CEU credits have received and completed required forms, and answering participant questions about the symposium.
I give permission to use photos of me that are taken during 2018 Diabetes Month and other community activities to be used in promotional materials and on the Coalition’s website.*
- Yes
- No
- By checking this box, I am stating that the information provided is true and accurate. I am also agreeing to become a Volunteer, and understand what is required by all volunteers. *
Comments
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