BellRinger Medical Volunteer Interest Form

Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

What is your date of birth? *

Gender *

Male
Female
Non-Binary
Prefer not to answer

Apparel Size *

Are you a cancer survivor?

Yes
No

Are you a cancer researcher?

Yes
No

Emergency Contact *

First

Last

Emergency Contact Phone Number *

Emergency Contact Relationship to You *

What is your role/department at MedStar Health (or other hospital)? *

to at clinical/first

Level of clinical/first aid training (e.g., RN, MD, etc.) *

All types of healthcare providers are welcome

Are you available to serve as a medical volunteer for BellRinger on Saturday, October 24? *

Half day - morning
Half day - afternoon
Full day
Not available

Do you have a car to be able to transport yourself outside of Georgetown? *

Yes
No

Are you willing to drive another volunteer to your volunteer location? *

Yes
No

Many of our volunteers do not have transportation to their volunteer locations. If you are able to help another volunteer get to your volunteer location, we'd be greatly appreciative. The BellRinger Team will work to arrange carpools and connect you with your co-volunteers to make for a seamless process.

Are you willing to receive a ride from another volunteer to your volunteer location? *

Yes
No

Are you comfortable driving a support and gear (SAG) vehicle? *

Yes
No

Support vehicles are minivans rented by BellRinger

Is there anything else you would like us to prioritize in your volunteer placement?

We will do our best to honor your wishes but cannot guarantee any specific requests - thank you for your understanding!

I have carefully read this Volunteer Participant Waiver, Release of Liability, & Assumption of Risk. I understand and agree to the terms laid out in the Volunteer Participant Waiver, Release of Liability, & Assumption of Risk.

Volunteer Waiver *

I accept
I do not accept