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. Please provide a copy of your current professional license, passport information page, diploma or student ID upon submission of the volunteer request form to info@wtlhealthclinic.org. We will process your application upon receipt of all required information.
Email address *
PERSONAL INFORMATION
First Name *
Your answer
Last Name *
Your answer
Middle Initial
Your answer
Date of Birth *
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Home Address *
Your answer
Phone number *
Your answer
EMERGENCY CONTACT
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Relationship to Emergency Contact *
Your answer
EDUCATION
College/University Name *
Your answer
Date of Graduation (Past or Anticipated) *
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DD
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YYYY
Major/Degree/Specialty *
Your answer
EMPLOYMENT
Where do you work? *
Your answer
Your position/title? *
Your answer
Work Address *
Your answer
Work Phone
Your answer
VOLUNTEER INFORMATION
Where are you interested in volunteering? *
Other, Please Specify
Your answer
Certification/Medical License # & Issuing State
Your answer
Preferred Start Date *
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YYYY
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 *
Your answer
Have you ever been charged with or convicted of any crime including either a felony or a misdemeanor?
If Yes, please describe where, when, and the nature of charge *
Your answer
How did you hear about WTL Health Clinic, Inc.?
Your answer
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