Mobile Migrant Health Team (Chicago) Volunteer Sign-up Form

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Thank you for your interest in volunteering with us!

Please fill out this form to be added to our volunteer directory and WhatsApp group.

First Name

Last Name

Institutional Affiliation (UIC, RUSH, etc.)

Phone Number

What is your current occupation?

Student (undergraduate)

Medical student M1

Medical Student M2

Medical student (M3-M4)

Dental student

Nursing student

Pharmacy student

PA student

RN or BSN

NP or APRN

MD or DO (resident)

MD or DO (attending)

Other:

Clear selection

If you have dual licensing, or have other forms of certification please list here:

Level of Spanish Fluency

None

I can understand it (record patient information spoken in Spanish)

I can understand & speak it a little (solicit symptoms & record them in Spanish)

I can understand & speak it well (have full conversations in Spanish)

I am a native speaker

Other:

Clear selection

Do you know any language other than English or Spanish? (If not skip)

Do you have a car to help transport supplies & people?

Yes

Clear selection

Potential Availability for Health Assessments

AM (9AM-1PM)

PM (2PM-6PM)

Evening (After 5PM)

Wednesday

Saturday

Are you interested in being in one of our committees?

Patient Follow-Up Team

Health Informatics Team

Sexual Assault Post-care Management Team

Community Resource Outreach Team

Clear selection

Submit

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