Centre Volunteers in Medicine - Volunteer Application

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Apply to Volunteer Today

1. Complete a volunteer application online below.

If you prefer, you can download and print a volunteer application and mail your completed application to our Volunteer Committee at the address on the form.

2. Attend a short orientation session to learn more about CVIM and the different areas where you can volunteer,
as well as receiving information and training about volunteering at a medical services organization.

We look forward to hearing from you soon!

ONLINE VOLUNTEER APPLICATION

(*) Required Fields

Last Name	First Name	MI	Title	Date (mm-dd-yyyy)
*	*			- - *
Local Address				Phone
*				- - *
City	State	Zip		Cellular/Pager
*	*	*		- -
Occupation				Email
				*
Are you a student? Check if yes If yes, Graduation Date:				May we contact your employer to verify your professional license and credentials? Yes No N/A
Are you RSVP Volunteer? Check if yes
Employer

Work Address				Work Phone
				- -
City	State	Zip		Fax
				- -

AVAILABILITY: Please check boxes to indicate when you are available to volunteer

Time	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
8:00 AM-1:00 PM
1:00 PM-4:30 PM
After 4:30 PM


COMMENTS/SPECIAL SKILLS:


VOLUNTEER POSITIONS
Clinical Services Social Services/Eligibility Dental Services Special Events/Development Administration/Office	Community Relations Data Entry Reception Greeting Medical Records Clerking

Professional Internship: If you are interested in a professional internship, indicate field and provide academic and contact information below:

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 below:

Have you been convicted of a felony within the past five years?** Yes No If yes, please explain below:

**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 below:

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 Committee.
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 Committee 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 agree to the terms stated above.
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