NHS Volunteer Internship Application

Neighborhood HealthSource Clinics Volunteer/Internship Application

We welcome individuals interested in learning more about working in a community health center. Volunteers and interns help us plan events, work on individual projects, assist with administrative tasks, participate in fundraising efforts, and connect with community members while gaining experience working in the world of healthcare and community health. This is a great opportunity for those looking for a career in public health or healthcare. You can also volunteer as a member of our board of directors. Our board is made up of 51% or more patients.
CONTACT INFORMATION
Full Legal Name

First NameLast Name
Name You Go By (If Different)
Pronouns
E-mail
Phone Number
Format: (000) 000-0000.
Permanent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
EMERGENCY CONTACT
Name

First NameLast Name
Relation to Applicant
Phone Number
Format: (000) 000-0000.

VOLUNTEERING/INTERNING EXPERIENCE CONT.
How did you learn about volunteering or interning at Neighborhood HealthSource clinics?

Other
Briefly describe your previous volunteer or interning experience(s).
Why do you want to volunteer or intern at Neighborhood HealthSource clinics?
What do you hope to gain by volunteering or interning?
Are there specific skills you wish you learn?
Are there specific skills you have that you would like to use in volunteering or interning?
What languages do you speak or write?
Is there anything else you would like us to know about your volunteering or interning experience?

BACKGROUND
Have you ever been convicted of or plead guilty to any violation of the law other than a minor traffic violation?
Please explain. (Note: answering “Yes” does not automatically disqualify you from volunteering with Neighborhood HealthSource. The nature and date of the offense will be considered.)
REFERENCES

List two references that are not family members or friends. This may include employers, teachers, and/or volunteer supervisors.
REFERENCE #1 Name

First NameLast Name
Email
Day Phone Number
Format: (000) 000-0000.
Company/Organization
Position Title (if applicable)
Relationship to Applicant
REFERENCE #2 Name

First NameLast Name
Email
Day Phone Number
Format: (000) 000-0000.
Company/Organization
Position Title (if applicable)
Relationship to Applicant

ACKNOWLEDGEMENT AND SIGNATURE
By signing below, I have given the preceding names as personal/professional references. I give permission for the release of reference information to Neighborhood HealthSource. I hereby release my references, my former employers, and all institutions and organizations for which I have volunteered, or are currently volunteering for, from all liability for furnishing this information.

By signing below, I hereby certify that all information I have provided in this application is true and complete. I understand and acknowledge that any false, misleading, or incomplete information in this application or during the placement process may result in rejection of my application or—if I have been placed—in termination of my volunteering.
Signature
Should be Empty:

Neighborhood HealthSource Clinics Volunteer/Internship Application