Guest Speaker Volunteer Application

Thank you for your interest in volunteering with Neil Kennedy Recovery Center (NKRC)! Please complete this application, and we will respond shortly.

Required: All NKRC Guest Speakers must have two or more years in a continuous manner of personal, lived recovery experience.

COVID-19 Vaccination Statement:
As mandated by the Centers for Medicare & Medicaid Services (CMS), COVID vaccination is required for all Neil Kennedy Recovery Center employees, practitioners, students, trainees, volunteers, or any other individual who provides care, treatment, or other services for NKRC and/or its patients or residents, under contract or by other arrangements. This CMS mandate is required in order to contract with Medicaid.

Legal First Name

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Legal Last Name

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Street Address:

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City:

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State:

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Zip Code:

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Date of Birth:

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Preferred Phone

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When is the Best Time of Day to Reach You?

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How did you learn about NKRC?

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What NKRC location(s) are you interested in speaking at?

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Why do you want to be a guest speaker at NKRC?

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What day(s) and hour(s) are you able to speak?

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Emergency Contact Name:

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Phone:

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Contact Relationship to you:

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I acknowledge that I do not have any family members receiving treatment at any NKRC location. If this changes, I will notify NKRC Staff immediately.

I acknowledge that I have two or more years in a continuous manner of personal, lived recovery experience.

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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