PROFESSIONAL VOLUNTEER APPLICATION
Name
*
Dr.
Mr.
Mrs.
Ms.
Prefix
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Type of phone
*
Please Select
Cell
Home
Work
Email
example@example.com
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Education (indicate highest completed)
*
Associates
Bachelors
Masters
Doctorate
Are you currently employed?
Yes
No
Where?
Job title
Preferred volunteer area
*
Dental
Medical
Vision
Days & times available (check all that apply)
*
Any
Mon AM
Mon PM
Tues AM
Tues PM
Wed AM
Wed PM
Thur AM
Thur PM
Fri AM
Fri PM
Can you commit to volunteering for at least 3 months?
Yes
No
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Are you fulfilling any type of required community service hours?
*
Yes
No
Please explain.
Do you have any limitations related to health?
*
Yes
No
Please explain.
Please indicate your professional certification.
*
MD
DO
PA
NP
RN
LPN
RMA
CNA/ CMA
DDS
RDH
RDA
OD
LDO
Other
Current TN license # (can only be TENNESSEE)
*
Please attach copy or picture
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NPI #
DEA # (optional)
Please attach copy or picture of any other specialty documentation.
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Are you currently covered under liability insurance? (liability is required)
Yes
No
Please attach copy or picture of proof.
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Are you a member of any professional Academy?
Yes
No
Which one?
Have you ever been convicted of a felony or crime?
*
Yes
No
Please explain.
Have you ever been subjected to professional disciplinary action?
*
Yes
No
Please explain.
Did a colleague refer you to Healing Hands?
Yes
No
Who?
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Emergency contact
*
First Name
Last Name
Relationship
Please Select
Significant other
Parent
Adult child
Sibling
Friend
Phone Number of Emergency Contact
*
Please enter a valid phone number.
I certify the statements I have made here are true and accurate. By signing this application, I agree that I render these health care services voluntarily and without compensation or the expectation of compensation. This acknowledgement and agreement has been made before rendering my services. I have been advised to review the Healing Hands Health Volunteer Handbook. I agree to report to the appropriate persons any incidents or injuries in which I am involved with during my volunteer service. I understand my service as a volunteer is covered up to the limits specified by the clinic's insurance program and I hereby waive any claim against Healing Hands Health except as specified therein.
*
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