Medication Cleanout

Abilene Medication Cleanout April 14, 2012
RequiredRequired Question(s)
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Volunteers are needed for the Medication Cleanout event on April 14, 2012 in Abilene, TX.  Please complete this form if you would like to volunteer.  At the end of the registration process, you will be redirected to a website to choose a shift.  Available shifts are: 9:30-1:30, 1:00-5:00, and 4:30-8:30.  All volunteers must be at least 18 years of age to volunteer and due to the nature of the event, no minors may be present in the volunteer areas.  Background checks may be performed.  A mandatory 1.5 hour training session will be required.  Time, date, and location of training to be announced in the near future.  Please contact the MCO Volunteer Coordinator at 806-351-5626 for any information or changes in your volunteer status.  If you are interested in volunteering, please complete the following: 

 
Required 1.

Please enter the information indicated below.  (Note - email will be used for all routine communication between organizers and volunteers.)


First Name:
Last Name:
Email Address:
emailaddress@xyz.com

Required 2.

We may need to reach you by phone on the day of the event.  What is the number of the cell phone that you will have with you? Please include area code.

 

50 characters left.
Required 3.

In the event of an emergency, please provide the name and telephone number of the person who we should contact on your behalf. Ex: John Doe, 806-555-1234.

 

50 characters left.
Required 4.

Have you participated in a Medication Cleanout event in the past?  If yes, please indicate location and date in comment box.

Yes
No
  • Comment:

  • 500 characters left.
Required 5.

With which group are you affiliated?

AISD
TTUHSC
Other  
  • Comment:

  • 500 characters left.
Required 6.

Laptops are needed to enter data gathered about the medication that is collected.

Will you bring a laptop with wi-fi internet access capability?

Yes
No
Required 7.

Are you bilingual (English and Spanish)?

Yes
No
  • Comment:

  • 500 characters left.
Required 8.

Volunteers will be required to wear the official Medication Cleanout t-shirt.  The Medication Cleanout t-shirt is short-sleeved, but you may wear your own long-sleeved shirt or sweatshirt underneath it. 

What size t-shirt do you need?

My Medication Cleanout t-shirt from the last event still looks good. I will wear the one that I already have.
X-Small
Small
Medium
Large
X-Large
2XL
3XL
9.

If you would like to volunteer, but have concerns about performing certain tasks (for example, cannot stand for long periods of time or need to avoid sun exposure), please explain below.

 

350 characters left.
Required 10.

Are you a pharmacist? (Note - It is not necessary to be a pharmacist to volunteer.  Some volunteer roles need to be filled by a pharmacist, but most do not and we need many, many volunteers.)

Yes
No
  • Comment:

  • 500 characters left.
Required 11.

Are you a pharmacy technician? (Note - It is not necessary to be a pharmacy technician to volunteer.  Some volunteer roles need to be filled by a pharmacy technician, but most do not and we need many, many volunteers.)

Yes
No
  • Comment:

  • 500 characters left.
Required 12.

Would you be willing and able to put a small sign in your yard the week of Medication Cleanout to increase awareness of the event?

Yes
No
  • Comment:

  • 500 characters left.