Epilepsy Services of Southwest Florida

Volunteer

Enter the following information.

Primary Contact Information

First Name

Last Name

Email Address

Address

Phone

City

Country

State

Zip Code

Tell us about yourself

Tell us about your previous Volunteer experiences

What community organizations do you belong

How did you hear about Epilepsy Services

Why do you wish to volunteer for Epilepsy Services

Are you seeking volunteer hours to meet school requirements
Yes
No

Name of School

Grade

School Phone Number

Name of School Contact

Position at School

Name of Emergency Contact

Phone Number

Any medical condition we need to be aware of while you volunteer
Yes
No

If you answered "yes" to the question above, please explain

Any additional information you would like to share with us?

I shall maintain client, staff and ESSWFL confidentiality and I shall hold confidential any information I obtain through volunteering, whether that be through written records or daily interaction with staff or clients. (Signed before starting to volunteer.)

Signed

Date

Verification Code

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Epilepsy ServicesOf Southwest Florida

Celebrating 50 Years

Volunteer

Primary Contact Information