Volunteer Information Form

About Sinclair Health Clinic:

Since 1986, Sinclair Health Clinic, formerly known as the Free Medical Clinic of Northern Shenandoah Valley, has been serving the medically underserved residents of the City of Winchester, Frederick County and Clarke County. The nonprofit’s mission is to improve the health of our patients through the work of our dedicated staff and supportive community. Our vision is that everyone in the Northern Shenandoah Valley has access to quality health care services. Our values include putting patients first in that we place patients above all other considerations and empower them to take ownership of their health within a community connected where we collaborate with patients, providers, and other organizations to foster community health.

In September 2017, the clinic announced that the Board of Directors had voted to change the organization’s name to the Dr. Terry Sinclair Health Clinic, doing business as Sinclair Health Clinic. The change was made to honor one of the clinic’s founders and its long time Medical Director, Dr. Terry Sinclair.

CURRENT VOLUNTEERS: Click 'YES' only if you are currently volunteering at the Clinic and are using this form to update your contact information.

yes

Your Name *

Prefix First Name Last Name Suffix

Birth Date *

Month Day Year

Email

example@example.com

Cell Phone Number

Area Code Phone Number

Can text and leave messages at this number?

Yes No

Home Phone Number

Area Code Phone Number

How do you prefer to be contacted? *

Cell phone call Cell phone text Email Home phone call

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Emergency Contact Name

Prefix First Name Last Name

Relationship to you

Spouse Parent Child Partner

Emergency Contact Phone Number

Area Code Phone Number

Which best describes you?

I am retired I am working full-time I am working part-time I am a student in college I am a student in high school

In which areas would you like to volunteer? Choose all that apply. *

Which of the volunteering activities interest you? Choose all that apply. *

Do you have any volunteering experience? If yes, please describe.

Do you have any medical degrees, certifications, or licenses that allow you to treat or see patients? If yes, please describe.

Do you speak fluent spanish?

Yes No I can understand some Spanish but I am not fluent.

Select your available days

From

: Hour Minutes AM/PM Option

To

: Hour Minutes AM/PM Option

Optional: list other schedule availability / information

Date *

Date

Signature *