COLUMBIA COUNTY VOLUNTEERS IN MEDICINE CLINIC, INC.

VOLUNTEER APPLICATION

NAME: ________________________________________________________________

ADDRESS: _____________________________________________________________

STREET CITY ZIP CODE

PHONE NUMBER: _____________________ BIRTH DATE: _________________

MONTH/DAY

ALTERNATE PHONE NUMBER(S): ______________________________________

PAGER NUMBER: _____________________

EMAIL ADDRESS: _____________________________________________________

CAN YOU SPEAK ANOTHER LANGUAGE, IF SO, WHAT?

__________YES __________NO LANGUAGE____________________________

PROFESSIONAL LICENSE

TYPE: _________________________________________________________________

LICENSE NUMBER: _______________________ EXP. DATE: _______________

PROFESSIONAL LIABILITY COVERAGE? ______YES_____NO

CARRIER/PHONE NUMBER: _____________________________________________________________

SKILLS

PLEASE LIST BELOW ALL SKILLS THAT YOU POSSESS WHICH WOULD BE HELPFUL IN THE CLINIC.

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FAVORITE HOBBIES: ________________________________________________________________________

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WHEN ARE YOU AVAILABLE TO VOLUNTEER?

DO YOU REQUIRE SPECIAL ACCOMODATIONS TO VOLUNTEER? IF SO, WHAT? ____________YES ____________NO

ACCOMODATIONS: ____________________________________________________

COMMENTS: ________________________________________________________________________

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DO YOU KNOW OF ANYONE WHO WOULD LIKE TO VOLUNTEER WITH US? ___________________________________________________________________

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CLINIC USE

LICENSE CHECKED/COPY ON FILE:__________________________________________

BACKGROUND CHECK: _______________________________________________

HEPATITIS B ________ PPD_________ ACLS_______ BLS________

VOLUNTEER TIME (DAYS/TIME):