Mazzoni Center

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Health Center Expansion Help make this vision a reality. Contribute to our Expansion Campaign. Contact Darrell Young at 215-563-0663 x222 or email dyoung@ mazzonicenter.org to find out how you can help.

Email Address *

Password*

Enter a password for your new account. If you currently have an account with us, enter your existing password. If you have forgotten your password you may have it reset and e-mailed to you.

Confirm Password *

If you do not have a previous account please confirm your password.

First Name*

Last Name*

Address 1*

Phone

Address 2

Cell Phone

City*

Age*

State*

Zip*

Emergency Contact Name

Emergency Contact Number

Emergency Contact Relationship

We would like to know who you are to help target volunteer opportunities that are most relevant to you.

Constituency

Gender

Sexual Orientation

Race/Ethnicity

May we leave a message for you?
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No

Please indicate if you are able to communicate fluently in any of the following:
Spanish
American Sign Language
TTY
Other:

Do you have a driver's license?
Yes
No

What is your schooling status?
Full-time
Part-time
Not in school

What is your current occupation?

Do you currently receive services at Mazzoni?

Yes
No

Have you ever received services from us?

Yes
No

Would you like to receive our email newsletter?

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Email preference

Text
HTML
Both

Your Skills:

Catering
Computers
Counseling
Desktop Publishing
Development
Entertainment
Fundraising
Grant Writing
Graphic Design
Photography
Public Relations

Public Speaking
Reception Desk
Research
Seminar/Workshop Design
Seminar Leadership
Telephone Solicitations
Typing/Data Entry
Video Production
Websites
Writing
Other:

Your Volunteer/Position Preference:

Food Bank
Health Center
Prevention Services
Open Door

Receptionist
Clerical/Office Aide
Special Events/Projects

Availability

I am generally available:	AM	PM
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays

Pledge of Confidentiality*

As a representative of Mazzoni Center, (formerly known as PCHA) I hereby state my understanding that the unauthorized disclosure of Mazzoni Center information violates clients' and the agency's right to privacy, and do hereby recognize my responsibility to hold such information in strict confidence. I agree not to disclose any such information to any person not also affiliated with Mazzoni Center or authorized by Mazzoni Center to have such information without specific consent of the individual or the Executive Director. The Violation of confidentiality is cause for immediate termination as a Mazzoni Center volunteer.

I have read and agree to adhere to the pledge of confidentiality.

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