Seasonal or Contracted Work Declaration

Seasonal or Contracted Work Declaration
This section is for individuals whose current employment is seasonal or contracted, where income may vary. We kindly ask that the information provided below is as accurate as possible. If there are any changes to employment or income, please let us know so we can keep your information up to date.
Patient Information
VIM Membership ID
Name

First NameLast Name
Date of Birth

MonthDayYear
Employment Information
When I am not actively working, I will rely on the following to meet my financial needs:

Savings from when I was workingSupport from family, partner, or other sources.Other
I understand that I must report any change in income status to Volunteers in Medicine Clinic Hilton Head Island.

By my signature below, I attest that the information provided is accurate, complete, and true to the best of my knowledge and belief. I acknowledge that any omission or inaccurate information could jeopardize my request for assistance.
Patient Signature

Clear
Today's Date

MonthDayYear
Date
Should be Empty:

Patient Information