Nurses and Clinical Support Volunteer Application

Nurses and Clinical Support Volunteer Application – Volunteers in Medicine

Apply to join our team as a Nurse or Licensed Clinical Support Volunteer. Please complete all sections of this application so we can best match your skills, experience, and interests to the clinic's needs. Please note: Nurses may volunteer at VIM as intake specialists even if they do not currently hold an active South Carolina nursing license.
Personal Information
Full Name*

First NameLast Name
Preferred Name
Date of Birth*

MonthDayYear
Date
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Emergency Contact Name*
Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Professional Information
License Type*
Professional License Number*
State of Licensure*
License Expiration Date*

MonthDayYear
Date
Board Certification
Specialty Area
Employment History
Current Employer
Position Title
Years of Clinical Experience*
YesNoRetiredPart-time
Primary Care ClinicWomen's HealthPediatricsChronic Disease ManagementPatient EducationScreening/TriageTelehealth SupportSpecial Projects
Availability
Monday MorningMonday AfternoonTuesday MorningTuesday AfternoonWednesday MorningWednesday AfternoonThursday MorningThursday AfternoonFriday MorningFriday AfternoonFlexible
WeeklyBiweeklyMonthlyAs needed
Credentials Upload
Upload Professional License*

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Upload Resume or CV*

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Upload Malpractice Insurance (if applicable)

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References
Reference 1 Name*
Reference 1 Relationship*
Reference 1 Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Reference 1 Email*
example@example.com
Reference 2 Name*
Reference 2 Relationship*
Reference 2 Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2 Email*
example@example.com
Background & Compliance
YesNo
If yes, please explain:
YesNo
YesNo
YesNo
YesNo
Statement of Interest
Please share your interest in volunteering and any relevant experience.*
Agreement & Electronic Signature
Signature*

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Date*

MonthDayYear
Date
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Nurses and Clinical Support Volunteer Application – Volunteers in Medicine

Personal Information

Professional Information

Employment History

Availability

Credentials Upload

References

Background & Compliance

Statement of Interest

Agreement & Electronic Signature