Volunteer Interest Form

OMDA - The Ohio Society for Post-Acute and Long-Term Care Medicine

Volunteer Interest Form


Prefix
First Name:
Last Name:
Suffix:
Credentials:
Title:
Facility:
Email:
Phone
Alternate Phone
Mailing Address: Business Home
Organization
Address:
City:
State
Zip
I would like to serve on the following committee/task force:
Communications Committee - includes Social Media, Newsletter and Website
Public Policy Committee
Membership Committee
Education Committee
   - denotes required fields