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Healthcare Provider Volunteer Application
Thank you for your interest in volunteering for The Clinic! We ask that you complete this application as a first step to becoming a volunteer.
How did you hear about us?
Have you worked or volunteered at The Clinic before?
Yes
No
If so, when?
Are you or family member currently served by The Clinic?
Yes
No
Name
Street Address
City
State
Zip Code
Email
Phone
Please tell us why you want to volunteer and what you hope to gain from the experience.
Please note any physical limitations.
Other language(s)
Proficiency
Native speaker
Fluent
Conversational
What volunteer opportunities interest you? (*License required)
Medical translation
Phlebotomist/Lab tech*
Physician (specialist)*
Nurse/Medical Assistant (RN/LPN/EMT)*
Behavioral Health
Please check the day(s) you are available:
Monday
Tuesday
Wednesday
Thursday
Friday
Please check the time(s) you ae available:
8:45-noon
12:45-4:00
4:00-6:00 (when available)
What is your time commitment?
Six months
One year
School year
Summer
How often would you like to volunteer?
1 time per week
Several times per week
Every other week
PA License or Certification type
PA License/Certification #
Expiration date
NPI number
DEA number
Date of birth
Social security #
Postsecondary/Undergraduate School
Program/Degree
Year of graduation
Medical/Graduate/Professional School
Program/Degree
Year of graduation
Are you Board Certified?
Yes
No
Profession/Specialty
Are you a member of a hospital staff?
Yes
No
Name of Hospital
Practice status:
Active
Retired
If retired, last date of practice:
Have you ever been involved in a current or pending malpractice action? (Please send documentation to wwellener@theclinicpa.org.)
Yes
No
Last Hepatitis B vaccine
Last PPD test
CPR certification
COVID vaccination
Have you ever been convicted of a crime?
Yes
No
If yes, please explain.
Reference Name
Reference Phone Number
The information contained in this application is correct to the best of my knowledge.
Submit
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