KEYSTONE STATE GAMES

Volunteer Medical Staff Information Form


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Section I.

Name:

Address:

City:

State:

Zip Code:

Business Phone:

Home Phone:

E-mail Address:


Section II.

Yes, I am willing to serve as a volunteer member of the Keystone State Games Medical Staff. I will be available on the following days (press the Ctrl button for multiple selections):


Tuesday, July 22

Tuesday Availability:

 

Wednesday, July 23


Thursday, July 24


Friday, July 25


Saturday, July 26


Sunday, July 27




Section III.

Please check:

Certified Athletic Trainer
Physical Therapist
Nurse
Physician, Specialty:


Athletic Training Student, School Attending:

EMT/Paramedic
Other


Section IV.

I am interested in the following:

CME Program (Date and Time TBA)

Workshop TBA (Date and Time TBA)


Section V.

Sport Preference:

1st Choice:

2nd Choice:


Section VI.

I will need housing for the following days:

Tuesday Evening
Wednesday Evening
Thursday Evening
Friday Evening
Saturday Evening


I will arrive: Day and Time:

I will depart: Day and Time:

Section VII.

I am not available for the 2008 Keystone State Games. Please contact me next year for the 2009 Games.