St Clare Health Mission Volunteer Application   

Please provide the following contact information:

First Name		Last Name
Street		City
State		Zip
Home Phone		Work Phone
Emergency Phone		Contact
E-mail		Occupation
Employer

Indicate Position you are applying for:

Clerical/Receptionist

Physician

Social Worker

Nurse

Med Asst

Pharmacy

Lab

Other (Please explain): 

Check what days you are Available:

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Morning
Afternoon
Evenings

Please provide applicable registration/license information:

Physician License Number
Pharmacy License Number
Nursing License Number
Other

History

Please check the communicable diseases you have had (if any)

Chicken Pox

Mumps

German Measles

Red Measles (7day)

Tuberculosis

Do you have physical limitations that would affect your volunteering?  No  Yes

Please explain Yes answer

Vaccination Record Dates

Diphtheria-Tetanus Booster:     Flu Vaccine: 

Oral Polio Series:    MMR: 

Dates for Required Health Screening

	Test	Date	Result
	Tuberculin Skin Test
	Rubella Titer

Hepatitus B Vaccine (optional)

Dates:

 

Signature: 

Date: 

 

Complete this form on-line and print it - Sign and date and mail to:  St. Clare Health Mission, 916 Ferry St., La Crosse WI  54601

or Fax to:  608-791-9570