AFMC Volunteer Application
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your highest education level?
*
High School
Associate
Bachelor's
Master's
PhD/MD
Are you a licensed healthcare provider?
*
Yes
No
Provider Information
What type of license do you have?
*
LPN/LVN
RN
NP/PA
MD/DO
If MD, what is your specialty?
*
Please provide your license number
*
License expiry date
*
-
Month
-
Day
Year
Date
Skills, Interests, and Availability
Describe your skills
*
Languages you have working proficiency in. Our most critical need is for volunteers that speak English and Spanish.
*
English
Spanish
Chinese
Vietnamese
Other
Tell us about your interest in volunteering with AFMC. Please be explicit if your interest includes the desire to get a letter of recommendation for pursuing a career in healthcare.
*
What is your availability?
*
Weekly (Preferred)
Two times per month
Once a month
Other
What is the total number of hours per month you are able to commit?
*
For our front line volunteers that are not licensed healthcare providers, we look for 8 AM to 12 PM commitment every Saturday plus 1 or 2 hours during the week. We are more flexible for licensed healthcare providers and back office volunteers.
How many months are you willing to commit?
*
For our front line volunteers that are not licensed healthcare providers, minimum we look for is 12 months of commitment. We are more flexible for licensed healthcare providers, Spanish interpreters, and back office volunteers.
Are there any mental or physical health impairments that would affect your ability to perform any of your duties, with or without reasonable accommodation, according to accepted standards of professional performance? If yes, please describe.
*
Please upload your resume or CV
*
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Your Signature
Signature
*
Date
Date
*
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