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Opportunities
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*Name:
*Date:
Address:
Home Phone:
*Cell Phone:
Work Phone:
Email Address:
Birthday:
Employer:
*Emergency Contact Name:
*Phone:
*How did you learn about our clinic?
Volunteer work interested in:
Physician
weekly monthly
Nurse Triage Lic. # exp.
weekly monthly
Registering patients during clinic days
weekly monthly
Administrative Projects
Filing and general office related duties
weekly M/T/W/Th
Computer input
weekly monthly
Website updating:
Technology expertise:
Ordering Supplies:
Project cleaning:
Community Awareness Opportunities
quarterly monthly
Caring Ball Fundraiser Assistance (September to February):
Underwriting, Facilities, Decorations, Silent Auction/Raffle, Reservations
*Volunteer Name:
Volunteer Role Assigment:
Start Date:
Orientation Date:
Orientation completed:
Calendar and Clinic Handout provided:
HIPAA form signed:
Tour of facility:
DL copied and in file:
Schedule Commitment:
Start Date:
Frequency:
Preferred Day:
Notes:
*Volunteer Signature:
*Date:
Executive Director Signature:
Date:
This field is required.