Application for Internship

828 Innes Ave.,
Suite 110
San Francisco, CA 94124

Fill out registration form below and
Submit button ( or print this page and send to HERC)

In exchange for your commitment, you will receive:

Free Training by the American Lung Association and/or Cancer Awareness Training
Certificate of Completion
An opportunity to help others
A small stipend

	Minimum Requirements: CA Driver's License or ID Must be fingerprinted Must have recent TB test
	I Accept/Have All the Requirements: YES NO

All starred (*) contact information must be filled in.
Personal information is for HERC'S use only and will be kept confidential.

First Name:*

Initial:

Last Name:*

Street Address:*

Apt :

Zip Code:*

Home Phone:*

Other Phone:

E-Mail:

I want to volunteer for:*

Asthma component

Cancer component

Select all that apply:

I am the parent of an asthmatic I know someone with breast, cervical or prostate cancer

I am an asthmatic I have medical experience

I know someone who’s asthmatic I have teaching experience

I have had breast, cervical or prostate cancer