• Volunteer Interest Form

    Please complete the form to the best of your ability. If we have openings that match your interests and availability, we will reach out to you to set up an interview.
  • I am 18 years or older.*
  • Date of Application
     - -
    2 digit month, 2 digit day, 4 digit year

  • Personal Information

  • Format: (000) 000-0000.
  • Are you a RSVP Volunteer?*
  • Are you a College Student?*

  • Volunteer Availability & Positions

  • I understand that I must be available for a full year to be considered for any volunteer position*
  • AVAILABILITY: Please indicate when you ARE available. Start times vary depending on position. **Please note, we are NOT open on Saturday and Sunday.***
    Rows
  • Volunteer Positions Available*

  • Clinical volunteer applications:  Please include a copy of your Pennsylvania clinical license or certification.  By my signature above and having checked yes to authorize contact, I grant Centre Volunteers in Medicine authorization to contact the employer, hospital, or health care facility listed on the front of this form for the purpose of verifying my professional license and credentials.

    Centre Volunteers in Medicine is committed to the policy that all persons shall have equal access to programs, facilities, and employment without regard to personal characteristics not related to ability, performance, or qualifications as determined by policy or by state or federal authorities.  Centre Volunteers in Medicine does not discriminate against any person because of age, ancestry, color, disability or handicap, national origin, race, religious creed, sex, sexual orientation, or veteran status.        

  • Are you bilingual?*

  • Additional Volunteer Questions

  • Have you had a PPD (TB) test in the past year?*
  • Clinical Volunteers: Have you been vaccinated against Hepatitis B? This is optional
  • Do you require any accommodations in order to perform the duties of a volunteer in the position which you are applying for?*
  • Have you been convicted of a felony within the past 5 years?*
  • Clinical Volunteers: Have you ever been required by any licensing board or professional ethics body to surrender your license, or have you ever been found guilty of professional ethics codes, professional misconduct, unprofessional conduct, incompetence or negligence, in any state or country?*

  • Additional Questions

    Our funders require us to collect the following information. You may choose to not answer.
  • How did you hear about CVIM?*
  • Which of the following best describes your race and ethnicity?
  • Which of the following best describes your gender?
  • Should be Empty: