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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.

Have you worked or volunteered at The Clinic before?
Are you or family member currently served by The Clinic?
What volunteer opportunities interest you? (*License required)
Please check the day(s) you are available:
Please check the time(s) you ae available:
What is your time commitment?
How often would you like to volunteer?
Are you Board Certified?
Are you a member of a hospital staff?
Practice status:
Have you ever been involved in a current or pending malpractice action? (Please send documentation to
Have you ever been convicted of a crime?
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