Current Results for Mid America Chapter Volunteer Form
1. Please fill in selected fields:
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2. Emergency Contact with Phone Number and Relation:
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Deborah Mc Indoo 816 875-8495
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Chris Chapman 320-262-0302 Fiance
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Byron Pendleton 8168131111 husband
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User Provided No Response
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View All Responses for question #2
3. Please advise any medical/allergy information:
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View All Responses for question #3
4. Please tell us your connection to multiple sclerosis:
Total Number of Responses 207 |
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5. Please indicate which of the following activities you are interested in:
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6. I have the following skills/experience that I am willing to utilize:
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7. I have the following certifications/licensing that I am willing to utilize:
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8. Is there anything else you'd like to tell us? Let us know below.
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View All Responses for question #8
9. I have read and I understand the Emergency Medical Treatment Authorization, Media Release and Right of Refusal/Dismissal. I agree to follow the Code of Conduct and Alcohol & Drug Use Policy outlined above. Enter your initials in the box below to agree:
Latest User Responses: |
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PDM
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KB
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TR
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Kate Pendleton
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DF
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