VOLUNTEER APPLICATION
Full Name
Date of Birth
Work Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Can we send you text messages?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Present Church
Vineyard Westerville
Vineyard Sawmill
Vineyard Grandview
Vineyard Pickerington
Vineyard New Albany
N/A
Other
Position of interest
Physician
Nurse Practitioner
Physicians Assistant
Nurse/ Paramedic
Pharmacist
Optometrist
Chiropractor
Prayer Team
Registration
Interpreter
Other
If you are currently working who is your current employer and what is your role?
If applicable what professional licenses do you hold? All medical licenses will be verified on elicenseohiogov
If you are a student where do you attend and what are you studying?
Do you speak any other languages beside English? If so what language?
What is your shirt size?
As part of the clinic we offer patient and community seminars. For example diabetes management. Are there any topics you would want to teach a class on?
Relevant experiences or certifications for volunteering
Why do you want to volunteer at the Vineyard Free Health Clinics?
References
Please list two professional references for us to contact regarding your ability to serve as a volunteer at the clinic.
Reference Name (1)
First Name
Last Name
Relationship to you (1)
Email (1)
example@example.com
Phone Number (1)
Please enter a valid phone number.
Format: (000) 000-0000.
Reference Name (2)
First Name
Last Name
Relationship to you (2)
Phone Number (2)
Please enter a valid phone number.
Format: (000) 000-0000.
Email (2)
example@example.com
Emergency Contact
Name
First Name
Last Name
Relationship to you
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
We currently offer clinics Tuesday evenings and Saturday morning. How often do you prefer to volunteer?
one time a month
two times a month
every week
What day of the week do you prefer to volunteer?
Signature
Date
/
Month
/
Day
Year
Date
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