Volunteer Provider Form | Al-Shifa Clinic

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Thank you for your interest in volunteering your time at Al-Shifa Clinic. We will be in touch with you shortly!

Email *

Name *

Phone Number *

Licensure *

Physician

Physician Assistant

Nurse Practitioner

Mental Health Counselor

Dentist

Dental Hygienist

Other

Required

Specialty (if applicable)

We schedule providers on a quarterly basis. Every 3 months, how many shifts would you be available for? *

Do you have liability insurance that will cover this volunteer work? *

Yes, I do not need liability insurance from the state.

No, I will need to sign up for liability insurance from the state.

A copy of your responses will be emailed to the address you provided.

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