Volunteer Application (Medical)
This application is for licensed medical professionals. Please complete the form below,  and our volunteer coordinator will call you do discuss next steps. Thank you so much for your interest in volunteering at the Albrecht Free Clinic.
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General Information
Please provide the following basic information. This will help us learn the best ways to contact you and provide necessary information to complete a background check if appropriate.
What is your legal name? *
Please include first name, middle initial, and last name.
Do you have any former names or nicknames?
What is your date of birth? *
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What is your primary phone number? *
Please indicate if this is a cell, home or business number.
Do you have any other phone numbers you'd like to share?
Please indicate if this is a cell, home or business number.
What is your email address? *
What is the best way to contact you? *
What is your street address? *
What is your city? *
What is your zip code? *
Have you ever been a patient at the Albrecht Free Clinic? *
How did you hear about the Albrecht Free Clinic? *
Please check all that apply.
Required
Professional and Community Experience
We're interested in learning how you stay busy!
Are you presently: *
Please check all that apply.
Required
If employed, where do you currently practice?
What is your role?
If retired, where did you practice?
What was your role?
Please describe any previous volunteer medical experience.
If applicable, please select your level of nursing experience.
If applicable, what type of provider are you?
Please list any type of professional license(s) you may have obtained in your career field, and would like to utilize in your volunteer work. *
Include license type and expiration date.
What are your special skills or areas of expertise? *
Is there any other pertinent information we should know about your medical experience?
The Albrecht Free Clinic offers 5 clinic times throughout the week. Patient volumes may vary depending on the schedule. Please select the shifts that you would be available.
Please note this does not mean you'd be scheduled every week. Most providers and nurses volunteer an average of 2 times per month.
References
Please list two individuals (other than relatives) who can tell us about your professional and community experience(s). You may also submit letters of recommendation. The Albrecht Free Clinic reserves the right to request an alternate reference.
Reference 1 *
Please list references name, phone number, email address and relationship to you.
Reference 2 *
Please list references name, phone number, email address and relationship to you.
Health
Are there any accommodations we need to make to facilitate your participation? *
Are you free of communicable disease? *
Have you had a Rubella test? *
Have you had a TB test? *
Have you received the COVID vaccine? *
Please note that the Albrecht Free Clinic follows the guidance of local healthcare providers. Currently, all volunteers should be vaccinated and masked to be inside the clinic.
Who can we call in case of an emergency? *
Please provide a name, phone number, and your relationship.
Background
The Albrecht Free Clinic reserves the right to complete a full background check.
Have you ever been convicted of a felony or misdemeanor or have any charges pending against you? *
Have you ever paid a civil fine or forfeiture for a non-traffic related offense? *
If yes to either question above, please provide an explanation of the offense(s), and the date(s) in which it/they occurred.
No applicant will be denied a volunteer position because of a conviction for an offense, a pending criminal charge, or payment of a civil forfeiture or fine which the Albrecht Free Clinic determined is not substantially related to the circumstances of the volunteer position sought.
Final Submission
I certify my answers to be true and complete. *
Today's Date *
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