Willing Helpers Medical Clinic Volunteer Application
Please fill out the form below if you are interested in volunteering with Willing Helpers Clinic.  We will get back with you within 24-48 hours with more information.  Thank you for your interest in caring for our patients!
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Name *
First and last name
Address (Street, City, State, Zip) *
Phone Number *
Email *
Birthdate (MM/DD/YEAR) *
Which position(s) are you interested in? *
Are you a U.S. Citizen? *
Have you ever been convicted of a felony? *
If Yes, explain:
Do you regularly attend a church? *
Where did you attend high school? *
Where did you attend college? *
Employment/volunteer work experience (current and/or previous)? *
Personal references (2 required with name, contact info, and relationship to applicant): *
I have read and understand the codes of conduct/guidelines/duties of each position: *
Electronic Signature - by typing your name below you agree that you have answered honestly and to the best of your abilities: *
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