VIM Lay Volunteer Application

VIM Lay Volunteer Application

Please complete this application to volunteer with VIM. Information is confidential and used for onboarding and placement.
Contact Information
Full name*

First NameLast Name
Preferred name
Pronouns (optional)
Date of birth*

MonthDayYear
Date
Phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Email address*
example@example.com
Home address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency contact name*
Relationship to emergency contact*
Emergency contact phone*
Please enter a valid phone number.Format: (000) 000-0000.
Volunteer Interests & Skills
Front desk / check-inPatient navigationInterpreting / language supportHealth educationPharmacy support (non-licensed tasks)Lab support (non-licensed tasks)Outreach/community eventsAdministrative supportFundraisingData entryIT/tech supportSocial media/communicationsFacilities/clinic supportOther (specify)
BilingualCPR/First AidCustomer serviceNonprofit experiencePrior healthcare/clinic experienceTranslation/interpretation trainingEMR experienceOther (specify)
Languages spoken and proficiency (e.g., Spanish – fluent, French – conversational)*
YesNoMaybe
YesNoMaybe
Availability
WeeklyTwice a monthMonthlyOne-timeAs needed
MondayTuesdayWednesdayThursdayFridaySaturdaySunday
MorningAfternoon
Date you can start volunteering*

MonthDayYear
Date
234Other
Any planned time away in the next 6 months? (optional)
Experience
Briefly describe any relevant volunteer or work experience*
YesNo
If yes, what role(s) and when?
Requirements & Compliance
YesNo
YesNo
YesNo
References
Reference 1: Name*
Reference 1: Relationship*
Reference 1: Email*
example@example.com
Reference 1: Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2 (optional): Name
Reference 2 (optional): Relationship
Reference 2 (optional): Email
example@example.com
Reference 2 (optional): Phone
Please enter a valid phone number.Format: (000) 000-0000.
Additional Information
Why do you want to volunteer with VIM?*
Do you need any accommodations to volunteer? (optional)
Anything else you’d like us to know? (optional)
Attestations & Signature
Electronic signature (type your full name)*
Signature date*

MonthDayYear
Date
Should be Empty:

VIM Lay Volunteer Application

Contact Information

Volunteer Interests & Skills

Availability

Experience

Requirements & Compliance

References

Additional Information

Attestations & Signature