Pediatric Cancer Departments Volunteer Application
Name
*
First Name
Last Name
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
Land-line Number
Cell-phone Number
Where Do You Want to Volunteer
*
Huda Al Masri Pediatric Cancer Department- Beit Jala
Dr. Musa & Suhaila Nasser Pediatric Cancer Department
You are a/an
*
Individual
School
Ministry
Company
Church
NGO
Mosque
Other
Please Fill- in the Name
*
Dates You Are Available to Volunteer- From
*
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Month
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Day
Year
Date
1
2
3
4
5
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9
10
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12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
To
*
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Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Please describe briefly your interest in volunteering at PCRF Pediatric Cancer Department, including relevant background/experience and the activity you are willing to make; if any
*
*
I hereby agree to all of the departments' policies regarding patient privacy, infection control, posting in social media, and respecting the medical and social obligations of the medical staff and PCRF staff in regards to any visits to the department.
Submit
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