Mount Pleasant Health Centre "Covid-19 Vaccination Clinic" Volunteer Application Form

Please note this form is only to apply to volunteer with us, completing it does not guarantee we will ask you to volunteer.

We do not get much notice for these clinics so would not expect you to be available for any of them - by completing this form we will only be adding you to the mailing list which then asks if you are available when we start planning them.

You can ask us to remove you from this list at anytime by emailing mountpleasantcontact@nhs.net

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* 1. First Name

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* 2. Last Name

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* 3. Date of Birth

Date of Birth

Date

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* 4. Email address

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* 5. Please confirm email address

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* 6. Contact number (will only be used for any same day queries)

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* 7. What GP Practice are you registered with (if not in Exeter, please also give the address)

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* 8. Have you previously volunteered for Mount Pleasant Health Centre

Yes

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* 9. Please tick the volunteer posts you would be interested in helping with

(Inside) Marshalling (E.g. Helping guide patients through the Health Centre to the vaccination clinic from various posts / taking patients temperatures as they arrive / guiding waiting patients to available vaccinators in the clinic area)

(Outside) Car Park Marshalling (E.g. Helping control traffic entering our car park as part of a team)

(Inside) Waiting room support (E.g. On our Pfizer clinics, helping the clinicians with managing the observation areas, wiping down seats, keeping patients to the 15 minute waiting time on their appointment cards)

(Outside) Screening Marshall (E.g. Asking patients our screening questions before permitting them entry to the building)

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* 10. If you have not yet been vaccinated we may be able to offer you the vaccine when you volunteer with us.

Have you had your covid vaccination (first dose)?

I do not want the vaccine

I've had both my First and Second doses

I have not had any covid-19 vaccination doses yet but would like to if possible

I'm waiting for my second dose (Please enter the type of vaccine and date you received the first dose)

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* 11. Are there any considerations we would need to make for you if you were to volunteer with us?

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* 12. As we cannot guarantee delivery dates we cannot provide dates far in advance. We will email out as soon as we begin planning any clinics and confirm with you as soon as possible.

Completing this form does not mean we will have you volunteer, it just means we will add you to our mailing list.

Please tick the box to confirm you're consent to receiving emails from Mount Pleasant Health Centre.

I confirm I am happy to receive emails from Mount Pleasant Health Centre relating to Covid Vaccination Clinic Volunteering

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* 13. Would you be interested in joining the Friends of Mount Pleasant Health Centre charity emailing list and receive information about our patient participation group?

Yes

Mount Pleasant Health Centre "Covid-19 Vaccination Clinic" Volunteer Application Form

Question Title

* 1. First Name

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* 2. Last Name

Question Title

* 3. Date of Birth

Question Title

* 4. Email address

Question Title

* 5. Please confirm email address

Question Title

* 6. Contact number (will only be used for any same day queries)

Question Title

* 7. What GP Practice are you registered with (if not in Exeter, please also give the address)

Question Title

* 8. Have you previously volunteered for Mount Pleasant Health Centre

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* 9. Please tick the volunteer posts you would be interested in helping with

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* 10. If you have not yet been vaccinated we may be able to offer you the vaccine when you volunteer with us. Have you had your covid vaccination (first dose)?

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* 11. Are there any considerations we would need to make for you if you were to volunteer with us?

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* 13. Would you be interested in joining the Friends of Mount Pleasant Health Centre charity emailing list and receive information about our patient participation group?

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* 14. Any other comments﻿/questions?

* 10. If you have not yet been vaccinated we may be able to offer you the vaccine when you volunteer with us.

Have you had your covid vaccination (first dose)?

* 14. Any other comments/questions?