Volunteer Application Form

Please complete this application form if you are interested in becoming a His Hands Free Clinic volunteer. Once you complete the form, click the submit button at the bottom.

Contact Information

Employment History

Please list your current or most recent employer, if applicable.

Demographics and Personal

You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers, and to demonstrate diversity within our organization.

Assignment Preference

The following volunteer assignments may currently be available. You may click the assignment names to learn more that assignment. Use this list to rank your top three assignment choices.

Emergency Contact

In the event of an emergency whom should we notify?


Please indicate the days and times you are usually available to volunteer.

Licensing Information

***This section to be completed by medical, dental, and chiropractic volunteers ONLY


If applying for a professional position (ie: doctor, nurse, dentist, ARNP, etc), or prayer support, please list two references, other than family members, who you give consent to the staff of His Hands Free Clinic to contact about your ability to serve as a volunteer.

I Agree

I understand and agree that submitting this application form does not automatically register me as a His Hands Free Clinic volunteer, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering.

I certify that the facts set forth in this volunteer application are true and complete to the best of my knowledge.

I authorize His Hands Free Clinic to verify their accuracy and to obtain reference information concerning my character and capabilities.

I release His Hands Free Clinic and any person or entity providing such reference information from any and all liability relating to the provision of such information or relating decisions made based upon such information.