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Good City Health Volunteer Form
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
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Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Next
Are applying to be a Medical or Non-Medical Volunteer for GOOD CITY HEALTH?
*
Please Select
Medical
Non-Medical
Medical (Physician, Nurse, Nursing Assistant, etc.); Non-Medical (Front Desk, Translation, Pastoral Care, Communication, etc.)
Current Occupation
*
Medical License / Title / Position
*
Have you ever volunteered in the medical field? If so, what did you enjoy about volunteering?
*
Please submit a copy of your up-to-date CV, preferably a PDF file.
*
Browse Files
Drag and drop files here
Choose a file
*NOTE: All MEDICAL VOLUNTEERS will be required to go through a credentialing and privileging process to volunteer in a medical capacity at GOOD CITY HEALTH.
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of
What position are you most interested in volunteering for? Select all that apply.
*
Front Desk
Translation
Pastoral Care
Communications
What volunteer work have you previously done? What did you enjoy most about volunteering?
*
*NOTE: All NON-MEDICAL VOLUNTEERS will be required to complete a background check.
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How frequently are you interested in volunteering?
*
Please Select
Once a week
Once a month
Multiple times a month
Once every couple of months
What days are you available to volunteer? Select all that apply.
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What languages do you speak proficiently? Select all that apply.
*
English
Spanish
Other
If you selected Other, please specify what languages you are proficient in.
Why do you want to volunteer with GOOD CITY HEALTH?
*
Submit
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