Alliance for Pharmaceutical Care Exhibit Volunteer Sign-up

Thank you for volunteering. Please complete the below information and submit your form. Further information will follow. Note that compensation and expense reimbursement is not provided by the Alliance.

First Name

Last Name

Mailing Address

Mailing Address Line 2

City

State

Zip Code

Phone Number

Email Address

You are a

Select your current status

Practice/ Employer

Degree

Which credentials do you posses? (Check all that apply)

Which patient care activities do you have experience doing? (Check all that apply)

Blood Pressures	Drawing capillary blood for cholesterol/ diabetes screening (Cholestec machines)
Using computerized Spirometers	Teaching how to use Peak Flow Meters
Using Sahara (Heel) Bone Density Screening	Conducting and Counseling on Body Fat Analysis
Counseling patients on cholesterol, diabetes, and medications	Counseling and screening patients for heartburn
Brown Bag Medication Reviews

I have the following equipment that I will bring with me for use during my time in the exhibit booth:

What days and time blocks do you want to work in the booth? (Check all that apply)
Note: You should arrive at least 30 minutes before shift begins.

For other times, please specify:

What areas within the booth do you wish to work (Check all that apply)

What pharmacy organization are you a memeber of? (Check all that apply)

American Association of Colleges of Pharmacy	American College of Clinical Pharmacy
Academy of Managed Care Pharmacy	American Pharmacists Association
American Society of Consultant Pharmacists	American Society of Health-System Pharmacists
National Association of Chain Drug Stores	National Community Pharmacists Association
State Pharmacy Association/ Society

I HAVE my own Insurance and am covered by my University's or Employer's Insurance Policy that covers my delivery of patient care activities (participanting volunteers must have existing coverage for activities not covered by the Alliance's contracted lab - eg. patient counseling, blood pressure measuring, screening/ monitoring activities, etc.).

Yes

No

Indicates Response Required

BPS - Pharmacotherapy	BPS - Nutrition
BPS - Other	Certified Diabetes Educator (CDE)
Certified Asthma Educator	CDM - Cholesterol
CDM - Diabetes	CDM - Asthma
CDM - Anticoagulation	Certificate Training - Cholesterol/ Cardiovascular
Certificate Training - Diabetes	Certificate Training - Asthma/ Respiratory
Certificate Training - Osteoporosis	Certificate Training - Smoking Cessation
Complete or are in a Pharmacy Practice Residency	Completed or are in a Community Pharmacy Residency

White Lab Coat (required)	Name Tag (recommended)
Blood Pressure Cuff	Stethoscopes
Other

Patient counseling (primarily about diabetes/ cholesterol)	Taking blood pressures
Cholesterol/ diabetes screening	Respiratory
Osteoporosis screening	Body Fat Analysis
Heartburn Screening/ Education	Brown Bag Medication Reviews