Health Clinic Volunteer Application

Vineyard Free Health Clinics 6000 Cooper Rd, Westerville, OH 43081 614.259.5512
VOLUNTEER APPLICATION
Thank you for your interest in volunteering with Vineyard Free Health Clinics. The first step is to complete this application. Upon submitting this form, you can expect to hear from our team within 3-5 business days.

If you have questions in the meantime, feel free to reach out to us at clinics@vineyardcolumbus.org. Thank you!
Full Name*
DOB*
Work Phone
Cell Phone*
Do we have permission to send texts to your cell phone?*

YesNo
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
POSITION(S) OF INTEREST - please select all that apply
Available positions:*

PhysicianNurse PractitionerPhysicians AssistantNurse / ParamedicPharmacistPharmacy TechOptometristChiropractorPrayer TeamRegistrationComputer Data EntryPatient CoordinatorsInterpreter
Present Church*
How long have you been attending that church?*
Who is your Sr. Pastor?*
What is your Sr. Pastors phone number?*
Can we contact your Sr. Pastor?*
When did you surrender your life to Jesus as Lord?*
Are you regularly attending a small group?*
If you are not regularly attending a small group, why not?*
If you are attending type N/A
What is your small group leader's name?*
Type N/A if you are not in a small group
What is your small group leader's phone number?*
Type 0000000000 if you are not in a small group
Can we contact your small group leader?*
Type N/A if you are not in a small group
Why are you interested in serving at the clinic?*
What languages do you speak other than English?*
If none, type N/A
If you speak another language, what level?*
If none, type N/A
We are considering offering patient/ community seminars. For example, diabetes management, stress management, etc. Are there any topics you would be willing to teach a class on. If so, what topic?*
If no, type N/A
REFERENCES: Please list two professional references for us to contact regarding your ability to serve as a volunteer at the clinic.
Full name (reference 1)*
Relationship to you (reference 1)*
Email (reference 1)*
Phone number (reference 1)*
Full name (reference 2)*
Relationship to you (reference 2)*
Email (reference 2)*
Phone number (reference 2)*
How often do you want to volunteer?*

Every week1x a month2x a month
What day(s) of the week would you want to volunteer?*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

VOLUNTEER APPLICATION

POSITION(S) OF INTEREST - please select all that apply