Please complete this application form if you are interested in becoming a Lehigh Valley Health Network Volunteer for our Covid-19 vaccination efforts. Once you complete the form, click the Continue button at the bottom.


Name and address


Demographic Information


Emergency Contact

Who should we contact in the event of an emergency?


Reference

Please enter the name of a reference. If you have been in contact with an LVHN Employee about this opportunity, please list them as well.


Employment

Please enter your current employer if you are a clinical provider or are able to give vaccinations.


Clinical or Non-clinical Volunteer

Please type in the box below what type of volunteer you are interesting in becoming: CLINICAL or NON-CLINICAL


Injections

If you are a clinical provider, have you given an intramuscular injection with in the past year? (If not, you will have an option to train to perform IM injections after competency has been completed) Please type YES in the box below if you have given an IM injection within 1 year. Please type NO if you have not but are interested in being trained to do so.


Agreement

I agree to complete the required documents and/or training before I volunteer with Covid-19 vaccination clinics at LVHN. Information will be provided to me by LVHN on how to proceed.