Volunteer Application Form

Volunteer Application Form

Please complete the application 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 acknowledge that I am applying to volunteer at Centre Volunteers in Medicine located in State College, PA*

Yes
Date of Application

MonthDayYear
Date
Personal Information
Name*

First Name & Middle InitialLast Name
Title
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Are you a RSVP Volunteer?*

YesNo
Are you a College Student?*

YesNo
When is your graduation date?
Employer
May we contact your employer to verify your professional license and credentials?

YesNoN/A
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship:*
Volunteer Availability & Positions
Are you able to commit to volunteering for one year? (You must be available for a full year to be considered for any volunteer position)*

YesNo

AVAILABILITY: Please indicate when you ARE available. Start times vary depending on position*

Rows	Morning	Afternoon	After 4:30 Medical Providers Only
Monday
Tuesday
Wednesday
Thursday
Friday

Volunteer Positions Available *You must be licensed/certified in PA to be considered for any clinical position. *There are no opportunities for shadowing in any clinical position at this time.*

Medical Provider MD, DO, CRNP, Chiropractor, etc. *Must have active PA LicenseRN or LPN *Must have active PA LicensePhysical Therapist *Must have active PA LicensePharmacist *Must have active PA LicenseDentist *Must have active PA LicenseLicensed Professional Counselor *Must have active PA LicensePsychiatrist *Must have active PA LicensePsychologist *Must have active PA LicenseFront Desk Receptionist *Monday AM, Thursday AM, Friday PMInterpreters *Monday AM/PM, Wednesday AM/PM, Thursday AM/PM, Friday AM/PM
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.
If you are interested in a professional internship, indicate which field and provide academic contact information.
Are you bilingual?*

YesNo
Please specify language(s)
Additional Volunteer Questions
Have you had a PPD (TB) test in the past year?*

YesNo
Clinical Volunteers: Have you been vaccinated against Hepatitis B? This is optional

YesNo
Do you require any accommodations in order to perform the duties of a volunteer in the position which you are applying for?*

YesNo
Please list required accommodations:
Have you been convicted of a felony within the past 5 years?*

YesNo
Please Specify the conviction:
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?*

YesNo
Please explain:

Do you have the following clearances? *

Rows	Yes	No - Will need to apply
Child Abuse Clearance
Pennsylvania State Police Clearance
FBI Clearance only required if you lived outside PA in the last 10 years

Additional Questions

Our funders require us to collect the following information. You may choose to not answer.
How did you hear about CVIM?*

Social MediaEmailVolunteer Centre CountyWord of MouthOther
Which of the following best describes your race and ethnicity?

Asian/Asian American/Pacific IslanderBlack/African American/AfricanHispanic/Latino/Latina//LatinxNative American/IndigenousWhite/Caucasian/EuropeanMultiracial/MultiethnicUnknown or decline to stateOther
Which of the following best describes your gender?

MaleFemaleNon-Binary (identifying as any gender other than female or male)Unknown or decline to state
Volunteer Agreement
1.       I shall keep confidential all information that I obtain regarding patients, staff, and volunteers.

2.       I shall submit to any immunizations that may be a necessary part of my volunteer service.

3.       I shall be punctual and conscientious, conduct myself with dignity, courtesy and consideration of others, and endeavor to make my work professional in quality.

4.       I agree to resolve any problems that may arise with the Volunteer Coordinator.

5.       I shall make my best effort to fulfill my commitment to the Clinic by volunteering at least four hours per month and by completing all assignments that I accept.

6.       I shall uphold the philosophy and standards of the clinic.

7.       I understand that the Volunteer Coordinator reserves the right to terminate my volunteer status as a result of:

a) Failure to comply with clinic policies, rules, and regulations.

b) Absences without prior notification.

c) Unsatisfactory attitude, work, or appearance.

d) Any other circumstances, which in the judgment of the Clinic staff would make my continued service as a volunteer contrary to the best interests of the Clinic.

I have read each of the above conditions and agree to be bound by them. I certify that the information I have given is complete, true and correct to the best of my knowledge and belief. I further affirm that I have not knowingly withheld any facts or circumstances in completing this application.
Signature*
Please verify that you are human*
Should be Empty:

Volunteer Application Form

Personal Information

Emergency Contact Information

Volunteer Availability & Positions

Additional Volunteer Questions

Additional Questions