Thank you for your interest in joining the volunteer team at the Free Clinic of SW Washington. This application is for STUDENT volunteers.

(If you are under the age of 18, please call the volunteer office at 360-313-1389 to discuss volunteer opportunities before filling out an application.)

After submitting your application, please allow up to TWO WEEKS for processing. You may then be contacted to arrange an interview or be placed on the waiting list depending on the position you are applying for.

Please note that completion and return of the volunteer application does not guarantee acceptance as a volunteer. All applications will be reviewed, verified, and kept on file. Please ensure that you enter a valid email address as this is a primary means of communication with applicants.

* indicates a required field.

Contact Information

First name:

Last name:

Middle:

Nickname:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

Cell phone:

Best Contact phone:

Email address:

Personal

Applicant Date of birth:

Employment Status:

Referred By:

Why do you want to volunteer and what do you hope to gain from serving at the Free Clinic of Southwest Washington?

Education

Employer:

Major (if applicable):

Name of school you are attending, Graduation date, Future career goal(s)? Do you plan to use these volunteer hours to fulfill an educational requirement? If yes, please explain.

Educational Intern or Externship

If you are part of an academic internship or externship, please describe it in the text field below. Include your SCHOOL, service start/end dates, & total hours needed.

Educational Institution:

Degree Program:

Service Start Date:

End Service:

Number of Hours:

Internship or Externship Details:

Skills and Motivation

Do you have particular experience or skills to share? Why do you wish to volunteer with Free Clinic? What motivates you to volunteer? Please provide details in the text field below.

Assignment

Please indicate your interests.

Work Preferences:

Prefer administrative work

Prefer clinical work

Prefer to work behind the scenes

Prefer to work on a 'project'

Prefer to work with patients

* Wait List:

Assignment

Importance

Primary interest? learning objectives?

Scheduling Preferences

Please indicate which days/times you are available to volunteer, as well as how frequently you wish to serve. Basic Care Clinic hours: Mon, Wed, Thurs - 9AM to 12PM & 1PM to 4PM, Tues - 1PM to 4PM & 6PM to 9PM, Fri - 9PM to 12PM (NO clinic first Friday of the month).

Emergency Contact Information

In case of emergency, who should we contact on your behalf?

First name:

Last name:

Home phone:

Work phone:

Cell phone:

Relationship:

Allergies, Alerts, or Emergency Instructions:

Reference / ID Verification

Note: A government photo ID is required at time of interview. Please list one professional and one personal reference with either phone or email.

1

2

First name:

Last name:

Title:

Email address:

Relationship:

Full Disclosure

Please disclose any criminal convictions and explain with the text field below. This disclosure does not automatically preclude volunteer service here but must be reviewed by FCSW. Learn more at the website 'requirements' page.

* Full Disclosure:

NO - There is nothing to disclose

YES - Action on License

YES - Criminal Conviction

YES - Current Complaint Filed w/ DOH

YES - Current Investigation w/ DOH

If yes, please provide details.

Additional Information or Comments

Is there anything else we should know about you?
Please use this space to provide any additional information, or questions you have.

How You Learned of the Free Clinic:

Church, temple or mosque

Flyer, brochure, newsletter

Free Clinic website

Friend, family or colleague/employer

Newspaper or radio

Other (please describe in box below)

School

Social media (Facebook, Twitter)

Volunteer Agreement

**REQUIRED READING!**

While some agencies may place volunteers in supplementary service roles, FCSW volunteers are the PRIMARY service providers. More than 600 active volunteers provide nearly all patient services, every year. As such, volunteers should be aware that their attendance at scheduled shifts is more critical than might otherwise be the case.

As a volunteer at Free Clinic of SW Washington I agree to:

* Honor the service commitment I make.

* Report on time for any scheduled shift.

* Notify my work supervisor ASAP if I cannot attend my scheduled shift.

* Comply with Free Clinic policies, programs and objectives.

* Respect FCSW employees and volunteer staff.

* Respect and maintain confidentiality in regard to personal and medical information of patients.

* Provide services with courtesy and respect to all patients.

* Communicate without delay any incidents, concerns, or disputes to the program lead staff person, or the volunteer manager.

The Free Clinic of SW Washington agrees to provide orientation, training and support to all new volunteers, as well as respect, support, and recognition of their efforts.

I CERTIFY that all statements I have made on my application are true and correct and I hereby authorize Free Clinic of SW Washington to investigate the accuracy of this information. I understand that I am working at all times on a voluntary basis, without monetary compensation or benefits, and not as a paid employee. As a Free Clinic of SW Washington volunteer, I give the Free Clinic permission to use my name with any photographs or videos made of me during my service without obligation or compensation to me and in such manner and at such times and in such places as Free Clinic of SW Washington, without restriction, at its sole discretion, shall determine. I understand that Free Clinic of SW Washington reserves the right to terminate a volunteer's services at any time.

I Agree