Volunteer Application Form
Thank you for your interest in Roots. Roots Community Health Center welcomes volunteers with a wide variety of backgrounds and interests, as well as interns, externs and students of all kinds. If you are looking for a unique opportunity to do community work in an underserved area, and at the same time learn new skills and make new friends, you are at the right place!
Contact Information
First Name *
Your answer
Last Name *
Your answer
Permanent Address *
Street, City, State, Zip Code
Your answer
Current Address
If different from above.
Your answer
Cell Phone *
Your answer
Alternate Phone
Your answer
Email Address *
Please note that email is our primary form of communication.
Your answer
How quickly do you reply to emails? *
Since email is our primary form of communication, we would like to know how promptly you respond.
Please provide an emergency contact. *
Include full name, phone number and relationship.
Your answer
Availability & Commitment
Roots Volunteers are expected to commit approximately 5 hours/week to volunteering for at least 6 months. If you are otherwise employed but still wish to volunteer, an exception may be made regarding the weekly hours requirement.

We offer volunteer opportunities in several areas. While we cannot guarantee that you will be placed in your top area of interest, we will attempt to place you there first. Depending on the length of your volunteer commitment, there may be opportunities to rotate through the different areas of service at Roots.

If you are a licensed clinician interested in volunteering at Roots, please select that option below and we will accommodate your schedule as needed.

Select the area(s) of service in which you are interested. *
Please check all that apply.
Required
Clinic Administration
Length of Commitment *
Please indicate how long you would like to volunteer with Roots.
Your answer
Which location(s) are you interested in working at? *
Required
Availability *
Please indicate your availability.
Required
Availability Details *
Please use this space to provide more information about your availability. If your schedule is subject to change, please let us know.
Your answer
Education & Employment
Educational Background *
Please list schools attended (such as high school, college, post-graduate) and any other training you'd like to share. Please include graduation year and majors, if applicable.
Your answer
Education Requirements/Credits *
Are you looking to volunteer in order to meet school requirements or for credit?
Education Requirements/Credits - Additional Info
If you answered "yes" to the above question, please tell us your school/program's name, and explain the requirements your volunteer commitment needs to meet (e.g., hours, type of work, timeline, supervision, etc.)
Your answer
Employment *
If you are currently employed, please tell us where, hours per week, job title, and any other information you'd like to share. If not, please type N/A.
Your answer
Are you currently seeking employment? *
Relevant clubs/organizations
Please list any relevant organizations or clubs where you have been involved in the past (or currently).
Your answer
Additional Information
Please indicate your reason(s) for volunteering. *
Required
Why are you interested in volunteering at Roots Community Health Center? *
Your answer
How did you hear about Roots? *
Your answer
If you have ever worked or volunteered in a clinic/hospital before, please list your responsibilities here.
Your answer
Do you speak/read/write any languages other than English? Please list and indicate ability for each language.
Your answer
Do you have any physical/mental/medical conditions that would affect your volunteer capacity? If so, please explain.
Your answer
What special skills, experience or knowledge would you bring to this volunteer opportunity? *
Your answer
Do you consider yourself to be compassionate? Responsible? Diligent? Punctual? Please explain. *
Your answer
Terms and Conditions
Please carefully read the following statements and input your initials if you agree/accept the terms.
I have answered each question fully and correctly. I understand that any deliberate misstatement will disqualify me, or will cause the immediate termination of my volunteer assignment.Initial and indicate that you agree/accept the terms. e.g., G.H (agree) or if you don't agree then G.H (disagree) *
Your answer
If accepted as Roots Community Health Center Volunteer, I agree that I am committed to at least 6 month of volunteer service and will volunteer a minimum of 5 hours a week for the duration of that 6-month (or 130 hours total as agreed upon). *
Your answer
If accepted as Roots Community Health Center Volunteer, I agree that I shall hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients, doctors, or personnel, and not seek to obtain confidential information from any patient. *
Your answer
If accepted as Roots Community Health Center Volunteer, I agree that my services are donated to the Roots Community Health Center without expectation of compensation or future employment. *
Your answer
If accepted as Roots Community Health Center Volunteer, I agree that I shall be punctual and conscientious, conduct myself with dignity, courtesy, and consideration of others, and endeavor to make my work professional in quality. *
Your answer
If accepted as Roots Community Health Center Volunteer, I agree that I shall attempt to resolve any problems related to my volunteer activities with my volunteer coordinator, and, if unsuccessful, attempt to resolve any such problems with the CEO of Roots. *
Your answer
If accepted as Roots Community Health Center Volunteer, I agree that I shall make my best effort to fulfill all assignments that I accept. *
Your answer
If accepted as Roots Community Health Center Volunteer, I agree that I shall at all times uphold the philosophy and standards of the Roots Community Health Center. *
Your answer
I understand that the Volunteer Services Department reserves the right to terminate my volunteer status as a result of (a) failure to comply with clinic policies, rules and regulations; (b) absences without prior notification; (c) unsatisfactory attitude, work, or appearance; or (d) any other circumstances which, in the judgment of the department director, would make my continued service as a volunteer contrary to the best interests of Roots Community Health Center. *
Your answer
I have read each of the above conditions and I agree to be bound by each of them. *
Your answer
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