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

PCHD Medical Volunteer Pool Application 
NAME
First   Middle Initial Last    
Address  
City  Altoona Ames Ankeny Bondurant Carlisle Clive Des Moines Elkhart Grimes Johnston Mitchelville Pleasant Hill Polk City Runnells Sheldahl Urbandale West Des Moines Windsor Heights   State Zip   

---

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 in Polk County: 
May, 2008
June, 2008
July, 2008




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

Also, be sure to add this email address to your email address book so we will be able to contact you via email: lpeacoc@co.polk.ia.us

 

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

© Copyright 2006-2007 - Polk County Government