The code block below illustrates how one might use # and // as comments in your logic and calculations.

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This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

BdTI2TvaIBLdL2B6knVZeBnMfhjvgVt7TeHcEFAJBatIHNK9WdfxaHd

Community-Engaged Learning Volunteer Application

Thank you for your interest in volunteering with Brock Virginia Health Sciences EVMS Community-Engaged Learning at Old Dominion University! We appreciate your time and commitment to the EVMS, ODU, and Hampton Roads communities.

Our team receives a multitude of Volunteer Applications. As such, after you complete the application, please allow us ample time to review your submission. We will contact you if we locate an excellent fit for the skills you are offering.

First Name

* must provide value

Last Name

* must provide value

Date of Birth

* must provide value

M-D-Y

Preferred Email Address

* must provide value

At this time, we are only accepting applications from the following licensed professionals:

MDs, DOs, RNs, NPs, LCSWs, Physical Therapists, and Certified Spanish Interpreters (Medical)

We welcome PAs, MAs, and Phlebotomy Technicians to submit a volunteer application, but cannot guarantee the availability of relevant volunteer roles.

* must provide value

I am an MD, DO, RN, NP, LCSW, Physical Therapist, or Certified Spanish Interpreter

I am a PA, MA, or Phlebotomy Technician

I do not hold any of the outlined licensure

Please upload your current resume

* must provide value

Upload file

Which unique skills would you like to volunteer?

* must provide value

Please indicate your availability below. Be as specific as possible.

e.g. "8 hours monthly. M,W,Th 10AM-2PM"

* must provide value

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Please list the Community-Engaged Learning initiative(s) you are interested in volunteering with below.

For more information about our initiatives, please click here to visit our website and learn more.

* must provide value

Please select the following vaccines and tests you have on file and up-to-date:

* must provide value

TDAP Vaccine (within the last 10 years)

2 MMR Vaccines

2 Varicella Vaccines

The Current Influenza Vaccine

IGRA Blood Test (within last 6 months)

QUANTitative Hepatitis B Titer (within last 6 months)

Respirator Fit Test (within last 12 months)

None of the Above

By checking this box, I understand that I may be required to provide record of receiving all listed vaccines and tests to EVMS Occupational Health during the onboarding process.

* must provide value

I understand

By checking this box, I understand that I may be required to schedule and receive all vaccines and tests listed above that I do not have.

* must provide value

I understand

By checking this box, I understand that I may be required to provide a copy of the respirator fit test I have on file to EVMS Environmental Health or schedule a fit test with the department if I do not have an up-to-date record.

* must provide value

I understand

If you would like to leave a comment or ask a question, please use this field to do so.

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