Clinical Volunteer Form

Greenville Free Medical Clinic

Licensed or Certified Clinical Volunteer Form
Name

First NameLast Name
I am a(n): *

Physician (MD/DO)DentistNurseNP/PA (MUST YOU OWN HAVE A SUPERVISING PHYSICIAN)PharmacistPhysical TherapistNursing AssistantMedical Assistant
Specialty
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Preferred Method of Contact (initial contact will be via email):

Phone callTextEmail
South Carolina License Number *
If you do not hold a current SC license, please complete the nonmedical volunteer application.
Hospital Affiliations (if applicable) *

Prisma HealthBon Secours St. Francis Health SystemSpartanburg RegionalOther or none
Hepatitis Vaccine #1 Date: *
Hepatitis Vaccine #2 Date: *
Volunteer Opportunities

PRIMARY CARE and SPECIALTY CARE: Main Clinic (downtown)

PRIMARY CARE ONLY: Satellite Clinics (Golden Strip, Northwest Crescent, and Greer)

DENTAL CARE: Main Clinic ONLY (downtown)
How did you learn of the Greenville Free Medical Clinic?
Are you currently employed? If so, where?
How often are you willing to volunteer?

WeeklyMonthlyQuarterly
Clinic Location Preferences:

Main Clinic/Downtown - Monday - ThursdayNorthwest/Crescent Clinic - THURSDAY ONLYGolden Strip Clinic - TUESDAY AND WEDNESDAY ONLYGreer Clinic - TUESDAY ONLY
Should be Empty:

Greenville Free Medical Clinic