Availability (check all that apply):

[  ] Monday  [  ] Tuesday  [  ] Wednesday  [  ] Thursday  [  ] Friday  [  ] Saturday

[  ] Mornings (approximately 9:00 am to 1:00 pm
[  ] Afternoons (approximately 1:00 pm to 4:30 pm)
[  ] Evenings (approximately 4:30 pm to 9:00 pm)

Please state the the day and results of your last TB test (Mantoux) if done within the past year:

Date:__________________________   Results:_________________________________

If positive, results of chest x-ray:______________________________________________

If you have not had a Mantoux test done in the last year, we may provide one for you free of charge.

What would you like to get from you volunteer experience?______________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

May we add you to the Boyle McCauley Health Centre fundraising database so that you may receive our annual fundraising mailout?

[  ] Yes   [  ] No

______________________________          ______________________________
Volunteer's Signature                                           Date Signed

Please return to:
Bavie Sara
Boyle McCauley Health Centre
10628 - 96 Street
Edmonton, Alberta T5H 2J2
Fax: (780) 425-8515