Volunteer Information Form

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.
Volunteer Opportunites
There are four distinct volunteer work areas from which you may choose. They are described below.

Once you have reviewed the volunteer work area information, please select the work area that most appeals to you.

The Clinic

Direct patient care: Provider, MA, etc. (certifications and licensure required)

Clinical Internship/Shadowing

Assisting as a medical scribe (proof of training/experience required)

The Pharmacy

Assisting with Medication pick-up/customer service

Assisting with Pharmacy Technician duties (certifications and licensure may be required)

Assisting with Lead Pharmacist duties (certifications and licensure required)

I am working with Jamie Huff on SU Pharmacy Internship

Community Engagement

Patient Enrollment Service and Support (in-person, by phone, and online)

Patient Case Management (connecting patients to assistance resources)

Volunteer Management

Fundraising and Community Events (planning and working)

Administration/Special Projects

Data input and management

Research and report management
Please Select Your Volunteer Area

Select one of the options below.
I have read the information above and I'd like to volunteer in this area*

I'd like to volunteer in the ClinicI'd like to volunteer in the PharmacyI'd like to volunteer in Community EngagementI'd like to volunteer in Administration/Special ProjectsI am seeking a PreceptorshipI am working with Jamie Huff on SU Pharmacy InternshipOther
You selected the CLINIC. Please choose all that interest you.

Direct patient care: Provider, MA, etc. (certifications and licensure required)Clinical Internship/ShadowingAssisting as a medical scribe (proof of training/experience required)Anything that is neededOther
You selected COMMUNITY ENGAGEMENT. Please choose all that interest you.

Patient Enrollment Service and Support (in-person, by phone, and online)Patient Case Management (Connecting patients to assistance resources)Marketing/Design: print, social, digitalVolunteer ManagementFundraising and Community Events (planning and working)Other
You selected the PHARMACY. Please choose all that interest you.

Assisting with Medication pick-up/customer serviceAssisting with Pharmacy Technician duties (certifications and licensure may be required)Assisting with Lead Pharmacist duties (certifications and licensure required)I am working with Jamie Huff on SU Pharmacy InternshipAnything that is neededOther
You selected ADMINISTRATION/SPECIAL PROJECTS. Please choose all that interest you.

Data input and managementResearch and report managementAnything that is neededOther
You requested a PRECEPTORSHIP. We consider all such requests on a case-by-case basis evaluating mission suitability and staff capacity. Please describe in detail what you are looking to accomplish and the proposed start and end dates of your requested preceptorship.
You are working with Jamie/SU PHARMACY INTERN. Please list the propesed start date/timeframe for your internship. Upon submission of this form you will receive a follow with links needed to complete our required training. Please let your SU faculty contact (Jamie or other) know when your required training is complete.
What is the timeframe of your SU internship (ie., Jan-April 2022)
Do you have any volunteering experience? If yes, please describe.
Do you have any medical degrees, certifications, or licenses? If yes, please describe.
Do you speak fluent spanish?*

YesNoI can understand some Spanish but I am not fluent.Other
Your Information
Your Name*

PrefixFirst NameLast NameSuffix
Birth Date*

MonthDayYear
Email*
example@example.com
Cell Phone Number

Area CodePhone Number
Can text and leave messages at this number?

YesNo
Emergency Contact

NamePhone Number
How do you prefer to be contacted?*

Cell phone callEmail
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
..
Enter the times you'd prefer to volunteer

If you can volunteer on more than one day per week, or have several possible timeframes, please list them in the optional box.
Select your available days
Please list your preferred schedule availability*
EX. Mondays 10a to 2p; Thurs 2p to 5p
A Few Things to Know

Please answe and mark as appropriate before submission.
Have you ever pleaded guilty or been convicted of a crime other than a traffic violation?*

YesNo
Date*

MonthDayYear
Date
Signature, sign below these words using your mouse*
Should be Empty:

Volunteer Information Form

Volunteer Opportunites

Please Select Your Volunteer Area

Your Information

Enter the times you'd prefer to volunteer

A Few Things to Know