Volunteer at Neighborhood Free Health Clinic Location: Stoughton, Wisconsin

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Thank you for your interest to volunteer with our team. We provide

Please fill out this form below and our clinic manager will contact you with the application materials!

Todays Date *

YYYY

Full Name: First and Last name *

Email address *

Phone number *

Preferred method of communication *

Phonecall

Text

Other:

Reference 1 *

Please share your 1st reference name, relationship to you, and their email address and/or their phone number.

Reference 2 *

Please share your 2nd reference name, relationship to you, and their email address and/or their phone number.

What volunteer role(s) are you potentially interested in? *

Medical Provider (Physician, Nurse Practitioner, Physician Assistant)

Housekeeping (vacuuming, bathroom cleaning; 2 hours weekly when clinic is not open)

Receptionist (clerical intake, volunteer coordination various times)

Patient Roomer (Nurse/Medical Assistant/CNA/EMT)

Fundraising Committee (collaborate for events)

Grant Writing Committee (research, draft, and submit)

Marketing (IT, Social Media, Community Outreach)

Other:

Required

Do you have any medical licenses (MD, NP, PA, CNA, etc.)? If so, list them here. *

Is there anything else you would like us to know? EX: fluent in another language or previous volunteer experience. *

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