: Directorate of Medical & Health Services, Uttar Pradesh

Directorate of Medical & Health Services, Uttar Pradesh

Toll Free No. For Mental Health Counselling - 14416

Reappointment Portal for Doctors/Specialists Covid Bed Availability Download "Mera COVID Kendra App" "Static Covid Test/Collection Centers" COVID Lab Report/Result Citizen Lab Result Portal/Result

उत्तर प्रदेश के स्वास्थ्य केंद्र उपचार (Covid Hospital Registration) Volunteer Registration OPD-IPD Registration Telemedicine Registration

खाद्य पदार्थों मे मिलावट और नकली दवाओं के प्रचलन पर रोकथाम से सम्बंधित सभी सूचनाएँ
सहायक नर्सेज एंड मिडवाइफ (ए. एन. एम.) प्रशिक्षण - 2023 के लिए चयनित कुल 2700 अभ्यर्थियों की अनंतिम सूची के क्रम में अंततः चयनित कुल 1800 अभ्यर्थियों की अंतिम सूची
सामान्य उपचारिका (जी. एन. एम.) प्रशिक्षण - 2023 के लिए चयनित कुल 1359 अभ्यर्थियों की अनंतिम सूची के क्रम में अंततः चयनित कुल 453 अभ्यर्थियों की अंतिम सूची
नोडल अधिकारी मा0 उच्च न्यायालय चिकित्सा विभाग में निजी निवेश के लिए ड्राफ्ट पालिसी

VOLUNTEER APPLICATION FORM

Name

Father/Husband Name

Date of Birth

/ /

Religion

Identity Card & Number (Any one)

ID Card Number

Education Qualification

Name of College

Address of College

Are you associated with any other Voluntary Organization?
Eg NSS, NYKS, Yuwak Mandal, Red Cross etc.

Which volunteer institution you are associated?

If Yes, How long you are the volunteer with your institution?

Years Months

Have you received any training on COVID-19 by your institution till now?

Name the volunteer association with which you are associated

Mobile/Telephone No 1:

Service Provider

Mobile/Telephone No 2:

Service Provider

Whatsapp Number

Service Provider

Email Id:

Communication Address

Address	* Required
Village	* Required
Block	* Required
District

Do you have any Medical/Health Problems?
Eg Hypertension, Diabetes, Heart Diseases, Kidney Diseases

Do you have any past illness in last six month due to which you have been admitted in hospital?

If Yes, What was the medical condition :-

Have you came in contact with CORONA positve patient in last 14 days?

If you are married female, Are you pregnant?

Do you have a Android Smart phone for your personal use?

Emergency Contact:

Name:-	* Required
Relation:-	* Required
Full Address:-	* Required
Mobile Number:-	* Required

Reference:

Name:-	* Required
Mobile Number:-	* Required
Occupation:-	* Required

Declaration:
I hereby certify that the information provided above is correct to the best of my knowledge.

04/07/2024

Date