Mr. Mrs. Ms. Miss Dr. Rev.

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Junior High High School Some College Associate Bachelor Advanced Degree

No Yes

No Yes

No Yes

No Yes

Previous service on any board, commission or position.

Resident Since *

Additional Information

Relevant Skills

Educational Background

Use the grid below to add each area of interest and number each in the order of your preference. *

ZIP *

Applicant Information

Areas of Interest

If Yes?

State *

Phone # *

Email *

Address *

In addition to English, do you speak any other languages? If so, please describe each and your level of proficiency (read, speak, write).

Name *

I understand that there are certain inherent risks that I am accepting as a volunteer in this program. I agree to strictly follow all directives and recommendations provided to me by the Camden County Department of Health and Human Services which are designed to minimize the risks of my exposure to disease or other adverse health effects. I also agree to immediately notify my supervisor should I observe any deviation from those directives and recommendations or should I, either intentionally or inadvertently, deviate from those directives and recommendations. I understand that my participation in this program is entirely voluntary and Camden County shall not be liable for any of the risks I am assuming as a volunteer.

Date of Birth *

Use the grid below to list all previous or current employers. (Attach a resume if you wish.)

If Yes Who?

Attach any files relevant to this application (Example, Resume, Certification or other) below. (1 Required) *

Have you traveled outside of the state in the last 14 days? Yes/no if yes where? *

Have you traveled outside the US in the last 14 days? Yes/No if yes where? *

Certification

Preferred Name

If Yes Where?

If Yes Where?

Employment History

Have you been in contact with anyone that has either tested positive or has displayed signs or symptoms of COVID-19? *

Use the grid below to list all education and training experience.

Apt, Suite, Unit, etc.

Title

Camden County Department of Health and Human Services COVID-19 Vaccination Clinic Team

City *

Have you presented with any signs or symptoms of COVID-19? *

Work/Business #

Sign Here *

By signing, I acknowledge that I have read, fully understand and agree to waive liability.

Highest Level of School Completed

Relevant work/professional experience, activities, certificates, etc.

Attachments

Cell Phone #