PA Vent Camp

VOLUNTEER APPLICATION
______________________________

First Name:
M.I.:
Last Name:
Street Address:
City:
State:
Zip Code:
Home Phone:
Work or Cell Phone:
E-Mail Address:
Age if under 18:
Position interested in:	Partner Nurse Team Leader RT Activities Junior Partner (13 & older) Junior Counselor (10-12)
School if nursing or RT student
Emergency Contact:
Emergency Contact Phone:

A copy of professional license or certification will need to be faxed to 717-531-0809 prior to camp.

For comments or suggestions about the PA Vent Camp Web Site, send an email to Robin Kingston at rkingston@psu.edu.

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