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. 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
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.
From

: Hour Minutes AM/PM Option
To

: Hour Minutes AM/PM Option
Please list your preferred schedule availability
EX. Mondays 10a to 2p; Thurs 2p to 5p
Have you ever pleaded guilty or been convicted of a crime other than a traffic violation? *

Yes No
Date *

Month Day Year
Date
Signature *
Should be Empty:

Volunteer Information Form

Enter the times you'd prefer to volunteer