Licensed Volunteer Application

Licensed Volunteer Application
This application is for licensed medical professionals and we thank you for your interest in
Hope Clinic of Ross County. Completion of this application and an orientation along with a
background check are required to be considered as a volunteer. Your background check can
be obtained at https://hopeclinicofrosscountyinc.quickapp.pro/apply/applicant/new/17347. If
you have any questions feel free to contact us at hopeclinic@hopeclinicfree.org.
I am a new volunteerI am a current volunteer applying per the bi-annual recertification requirements
My licensed medical field is*
Contact Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number*
Is this a:*

Mobile deviceWork numberHome number
Secondary Phone Number
Is this a:

Mobile deviceWork numberHome numberNo secondary number
Email Address*
Birth Date*
Specialties

Enter N/A where necessary
Primary Specialties*
Secondary Specialties*
Education
Please list the institution(s) you attended and your graduation year*
List your major/degree*
License/Certification
License Number*
Type of License*
Date of Expiration*
Status of licensure*

ActiveInactive
State license is issued from*
Physician/NP and PA - please provide the following. (Non physicians/NP and PA please complete with N/A)
DEA #*
NPI #*
Current Employer
Employer Name*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Teaching History

Enter N/A where necessary
Please provide institution/facility, position/class and dates
Background Information
Have you ever been named a defendant in any criminal proceeding?*

YesNo
If yes, please provide a full explanation. If no, please type N/A*
I give Hope Clinic of Ross County, Inc. permission to check the NPDB website to query about my licensing information. The National Practitioner Data Bank (NPDB) is a web-based repository of reports containing information on medical malpractice payments and certain adverse actions related to health care practitioners, providers and suppliers. This is a requirement of FTCA accreditation with which we are affiliated.*

Permission granted
Professional References
Provide the name and address of at least two peers who have had recent extensive experience in
observing or working with you who can provide information pertaining to your present clinical
competence, character and ability to work as a member of a healthcare team. At least one of these
peers must share your same professional credentials. None of these individuals are to be related to
your family or have current or impending professional or financial associations with you or your family.
Reference #1
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Employer*
Primary Phone*
Please enter a valid phone number.
Secondary Phone (Please enter X if not submitting secondary number) *
Please enter a valid phone number.
Email Address*
example@example.com
Relationship*
Reference #2
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Employer*
Primary Phone*
Please enter a valid phone number.
Secondary Phone (Please enter X if not submitting secondary number) *
Please enter a valid phone number.
Email Address*
example@example.com
Relationship*
Independently Licensed Professionals
Please provide your Hospital Affiliation(s)*
Dates worked*
Status*
Department/Specialty*
Board Certifications

Type N/A where necessary
Specialty*
Certificate*
Issue Date*
Renewal Date*
Expiration Date*
Hope Clinic Core Values

At Hope Clinic we desire to treat our patients, volunteers and guests as we would want to be treated. We value volunteers who are kind compassionate, caring and non-judgmental. Every human has a story and not every story is the same. This is why we strive to genuinely care for the needs of others and remind them that we want to share their burden and improve their health in as many ways as we can. We want to reserve judgment about WHY there is a need and focus our time and talents on MEETING THAT NEED. We pray that our clinic could be the hands and feet of Jesus in our community. While volunteering at Hope Clinic I will conduct myself with these values in mind. I also understand that by submitting this form I attest the information I have provided is true and accurate and that completing this application does not automatically register me as a Hope Clinic volunteer.
Agree
Acknowledgement/Agreement
As part of my volunteer service at Hope Clinic, I agree that my licensure and credentials will be verified prior to the beginning of my service and every two years thereafter. I certify that I have not voluntarily lost or had my privileges and/or duties reduced at another healthcare facility, that I have maintained all relevant licensure, received all relevant and required education and am in all ways capable of providing medical care as a volunteer at Hope Clinic of Ross County, Inc. I further agree that should my ability to perform duties change, I will notify clinic personnel immediately to either change the scope of or terminate my volunteer service. I understand that any misrepresentation, misstatement or omission regarding this application, whether intentional or not, may constitute cause for rejection of this application resulting in denial of appointment. I understand that in the event my appointment has been granted prior to the discovery of misrepresentation, misstatement or omission, such discovery may result in summary dismissal from Hope Clinic of Ross County, Inc. medical staff.*

Agree
Should be Empty:

Licensed Volunteer Application

Contact Information

Specialties

Education

License/Certification

Current Employer

Teaching History

Background Information

Professional References

Reference #1

Reference #2

Independently Licensed Professionals

Board Certifications

Hope Clinic Core Values

Acknowledgement/Agreement