Esperanza Health Center Volunteer Form
Esperanza's Mission: “Compelled by the love of God in Christ Jesus, in cooperation with the Church and others, Esperanza Health Center is a multi-cultural ministry providing holistic healthcare to the Latino and underserved communities of Philadelphia.”
Email address *
Date
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Name *
Your answer
Address
Your answer
State
City
Your answer
Zip
Your answer
Home #
Your answer
Cell #
Your answer
Email
Your answer
Are you employed?
If yes, Employer & Title
Your answer
Are you a student
If yes, School & Grade/year
Your answer
Are you 18 years of age or older?
Emergency Contact & Relationship; Phone:
Your answer
Your Level of Spanish fluency: Speaking
Your Level of Spanish fluency: Reading
Your Level of Spanish fluency: Writing
What volunteer areas are you interested in? (Check all that apply)
Please list any skills you possess in order to perform the above volunteer tasks
Your answer
Please list any accreditations, licensures, trade memberships, or certifications
Your answer
Desired Start Date
MM
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DD
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YYYY
Projected End Date
MM
/
DD
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YYYY
Frequency of availability
Number of hours availability each time you volunteer
Please list the time frames you are available to volunteer ( Clinic is open M-F 9am-5pm). Start Time and End Time.
Your answer
Preferred clinic location (s):
Why do you want to serve at Esperanza Health Center?
Your answer
Esperanza Health Center is a Christ-centered ministry. Have you had experience participating in a ministry setting?
If yes, describe your experience
Your answer
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