Volunteer Registration Form

Volunteer Registration
Name*

First NameLast Name
Category
Name of Organization/Vendor
E-mail*
Phone Number*

Area CodePhone Number
Home/Organization Address ( Thank you cards will be mailed to this address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Bilingual (English/Spanish) (Preferred since target population is Latino)*
Health Fairs

Donnelly College KCK (9/21/13) 8am-4pmTopeka (10/5/13) noon-4pmWichita (10/5/13) TBAKCK El Centro (10/12/13) 9am-2pmBinational Health Week KC, MO (10/15/13-10/18/13) 10am-2pmLawrence (10/26/13) 10am-2pmOlathe (11/17/13) 10am-5pmLiberal, KS (11/23/13-11/24/13) 9am-5pmGarden City, KS (12/7/13-12/8/13) 9am-5pm
Activity (May Change Depending on Availability of Volunteers)

RegistrationSet-up/CleanBMINutrition EducationGlucoseInterpreterBlood PressurePhysical Activity
Message
Please contact Andrea at adachiardi@kumc.edu if you need to cancel or have any questions.
Should be Empty:

Volunteer Registration