Volunteer Application Form
We consider applicants for all volunteer positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation or any other legally protected status.
Have you been a patient of the Volunteer Healthcare Clinic within the last three months? *
Personal Information
Full Name *
Your answer
Preferred Name *
Your answer
Birth Date *
MM
/
DD
/
YYYY
Email Address *
Your answer
Phone Number *
Your answer
Physical Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Employer
Your answer
Volunteer Services
Please mark “X” in the area in which you are licensed and provide you license number:
License type and number (if applicable):
Your answer
Please mark “X” in the area you have skills or interest: *
Required
Please list your Occupation / Specialty *
Your answer
Language Skills
Do you speak fluent Spanish? *
Do you speak any other languages? (Please list)
Your answer
Schedule Preferences
(For Doctors & Advance Practice Nurses Only)
Preferred Clinic Night?
Do you have privileges at any local hospital(s)?
Your answer
Volunteer Experience / Goals
Have you volunteered elsewhere? If so, where? *
Your answer
Why do you want to volunteer at Volunteer Healthcare Clinic? *
Your answer
List any other skills or experience (such as website design, marketing, writing, fundraising) *
Your answer
How did you hear about us? *
Your answer
References
Reference 1: Name
Your answer
Reference 1: Phone Number
Your answer
Reference 2: Name
Your answer
Reference 2: Phone Number
Your answer
Conviction Record Statement
Have you ever been convicted of, or received deferred adjudication for, a crime? *
If yes, please explain:
Your answer
Agreement
By submitting this form, I authorize any inquiry to be made on any information contained in this application if I am considered for volunteer placement, which will include a background check. I understand that all files and records maintained by the Volunteer Healthcare Clinic (VHC) are privileged and confidential. Any and all information that I may have access to may not be released or communicated to others unless authorized by the Executive Director or staff member who has also been authorized by the Executive Director to make that determination. I understand that I will be expected to treat all patients, volunteers and staff with respect. I understand and consent that any photos or video taken of me while at the Clinic can be used for Clinic purposes. I acknowledge my understanding of the conditions of my voluntary service for VHC and acknowledge and understand that I must conform to the rules and regulations of VHC to the best of my ability or my voluntary services may be terminated.
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