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Pinckneyville Community Hospital

Auxiliary Interest Form

Fill out form below.
* Name
* Date
  Address
  City
  State
  Zip Code
* Home Phone
  Cell Phone
  Email Address
  Are You Over 18?
  How many times a week would you be interested in volunteering?
Availability: Please mark your GENERAL availability. Please note, this is not a commitment.
  What day/s are you available? Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
  What time of day are you available? 7 am - 9 am
9 am - 11 am
11 am - 1 pm
1 pm - 3 pm