Home Maps /Directions Contact

  SEARCH     Things To Do     Services     Offices/Departments     Elected Officials  

Welcome to the Polk County Health Department

Home About Us Administration Services News Calendar of Events Forms FAQ'S Related Links Contacts Español

Medical Volunteer Pool Application 
NAME
First   Middle Initial Last    
Address  
City  Ackworth Adel Alleman Altoona Ames Ankeny Bagley Bayard Bondurant Booneville Bouton Carlisle Casey Clive Cumming Dallas Center Dawson De Soto Des Moines Dexter Earlham East Peru Elkhart Farrar Granger Grimes Guthrie Center Hartford Indianola Jamaica Johnston Lacona Liberty Center Linden Macksburg Medora Menlo Milo Minburn Mitchelville New Virginia Norwalk Panora Perry Pleasant Hill Polk City Redfield Runnells Sandyville Sheldahl St. Charles St. Marys Stuart Truro Urbandale Van Meter Waukee West Des Moines Windsor Heights Winterset Woodward Yale   State Zip   
County  Dallas Guthrie Madison Polk Warren  

---

PHONE (format 999-9999 or 999-999-9999)
Work Cell Home  
Email Fax  

---

Profession  
Current Employer
Current Professional License Number
License Type  DO LPN MD Nurse Practitioner PA Pharmacist RN



Special Skills  SpanishBosnianHmongArabicSomaliVietnameseSign Language

---

Emergency Contact   Contact Phone   Secondary Phone  
 Relationship to you

---

Are you committed to volunteer your services for any other agency? YesNo
What agency?  
 
Check the months you are available to volunteer if a disaster occurred: 
February, 2012
March, 2012
April, 2012




Make sure your email address is correct before clicking the submit button. This is what we will use to contact you monthly for your availability.  

Also, be sure to add this email address to your email address book so we will be able to contact you via email: Christine.Schumann @polkcountyiowa.gov

 

Top of Page | Health Department Home | Polk County Home | Contact Us | Disclaimer

© 2012 Polk County Government