Student Application Form Page 2
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4Volunteer Health Screening
Volunteer Name: ____________________________
(Please Print)
I certify that I am in good health and am free of communicable diseases that
could be transferred to or present a health risk to the Residents of this facility.
I am physically, mentally and occupationally capable of performing the tasks for
which I am assigned and performing while at this facility.
Volunteer signature: __________________________ Date: _____________
Feb 2013
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