Chronic Disease Lay Leaders Registration Form
1.
Please enter the information indicated below.

By entering my personal information, I consent to receive email communications from the survey author's organization based on the information collected.

First Name:
Last Name:
Work Phone:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
City:
State/Province
(US/Canada):
Postal Code:
Age:
Ethnicity:
Your Cell Phone:

2.

Do you have access to a phone to make weekly calls to individuals?
Yes
No
3.

 Do you have access to the internet? 
Yes
No
4.

 Do you have access to a webcam? (If you do not, this does not exclude you).
Yes
No
5.
Are you comfortable using virtual platforms such as Zoom for meetings and/or workshops? 
Yes
No
6.
During which hours are you available for volunteer assignments? 
(you can select more than 1 answer) 
Weekday mornings
Weekday afternoons
Weekday evenings
Weekend mornings
Weekend afternoons
Weekend evenings
7.
Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports.  
 

350 characters left.
8.
Summarize your previous volunteer experience.  
 

350 characters left.