WTL Health Clinic Volunteer Request Form
Thank you for your willingness to give! Our volunteers are the reason we are able to offer free health care. Where applicable, please provide a copy of your current professional license, passport information page, drivers license, diploma or student ID upon submission of the volunteer request form to admin@wtlhealthclinic.org. We will process your application upon receipt of all required information.
Email address *
PERSONAL INFORMATION
First Name *
Last Name *
Middle Initial
Date of Birth
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Home Address *
Phone number *
EMERGENCY CONTACT
Emergency Contact Name *
Emergency Contact Phone Number *
Relationship to Emergency Contact *
EDUCATION
College/University Name *
Date of Graduation (Past or Anticipated) *
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Major/Degree/Specialty *
EMPLOYMENT
Where do you work? *
Your position/title? *
Work Address *
Work Phone
VOLUNTEER INFORMATION
Where are you interested in volunteering? *
Other, Please Specify
Certification/Medical License # & Issuing State
Preferred Start Date *
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Preferred End Date *
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Do you have any physical limitations or medical conditions that would prevent you from safely doing the task you are applying for? *
If Yes please describe
Have you ever been charged with or convicted of any crime including either a felony or a misdemeanor?
Clear selection
If Yes, please describe where, when, and the nature of charge
How did you hear about WTL Health Clinic, Inc.?
Submit
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