|
Volunteer Application |
| |
|
| (*) Required Fields |
|
| Last Name |
First Name |
Title |
Date (mmddyyyy) |
|
* |
* |
|
-
-
* |
| Local Address |
Phone |
|
(
)
-
* |
| City |
State |
Zip |
Cellular/Pager |
|
* |
* |
* |
(
)
-
|
| Are you a student?
If yes, Graduation Date:
|
Email |
| RSVP Member
|
* |
| Occupation |
May we contact your employer to verify your professional license and credentials? |
|
| Employer |
|
Yes
No
N/A
|
| Work Address |
Work Phone |
|
(
)
|
| City |
State |
Zip |
Fax |
|
|
|
(
)
|
| |
Volunteer Interests |
Clinical Services
Socal Services/Eligibility
Dental Services
Special Events/Development
Administration/Office |
Community Relations
Data Entry
Reception
Greeting
Medical Records |
| |
| What attracted you to Centre Volunteers in Medicine?* |
|
| Have you had a PPD (Tuberculosis) test in the past year?.* |
|
Yes
No |
| |
| Clinical Volunteers: Have you been vaccinated against Hepatitis B? This is optional. |
|
Yes
No |
| |
Do you require any accommodations in order to perform the duties of a volunteer in the position for which you are volunteering?
Yes
No
If yes, please explain: |
|
Have you been convicted of a felony within the past five years?**
Yes
No
If Yes, please explain: |
|
| **Note: A conviction will not necessarily bar you from volunteering. Each conviction is judged on its own merits with respect to
time, circumstances, and seriousness. |
| |
| Clinical Volunteers Only: Have you ever been required by any licensing board or professional ethics body to surrender your license, or have you ever been found guilty of professional ethics codes, professional misconduct, unprofessional conduct, incompetence or negligence, in any state or country? |
Yes
No
If Yes, please explain: |
|
| |
Volunteer Agreement |
- I shall keep confidential all information that I obtain regarding patients, staff, and volunteers.
- I shall submit to any immunizations that may be a necessary part of my volunteer service.
- I shall be punctual and conscientious, conduct myself with dignity, courtesy and consideration of others, and endeavor to make
my work professional in quality.
- I agree to resolve any problems that may arise with the Volunteer Coordinator.
- I shall make my best effort to fulfill my commitment to the Clinic by volunteering at least four hours per month and by
completing all assignments that I accept.
- I shall at all times uphold the philosophy and standards of the Clinic.
- I understand that the Volunteer Coordinator reserves the right to terminate my volunteer status as a result of:
- Failure to comply with clinic policies, rules, and regulations.
- Absences without prior notification.
- Unsatisfactory attitude, work, or appearance.
- Any other circumstances, which in the judgment of the Clinic staff would make my continued service as a volunteer contrary to
the best interests of the Clinic.
I have read each of the above conditions and agree to be bound by them. I certify that the information I have given is complete, true
and correct to the best of my knowledge and belief. I further affirm that I have not knowingly withheld any facts or circumstances in
completing this application.
|
| |
| |
|
|
I agree to the terms stated above. |
|
|
|
|
|
|
|
|
|
