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. This is used only to help us recognize the diversity/demographic make-up of our volunteers.



Assignment Preference

The following volunteer assignments may currently be available. Click the assignments to rank your top three choices.



Emergency Contact

In the event of an emergency, whom should we notify?



Availability

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



References

If applying for a professional position (ie: doctor, nurse, dentist, ARNP, CMA, etc.), or prayer support, please list two references, other than family members. By providing names, you consent to His Hands Free Clinic staff contacting your references regarding your volunteer application.



I Agree

I understand and agree that submitting this application form does not automatically register me as a His Hands Free Clinic volunteer. There are certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I 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 persons or entity providing such reference information from any and all liability relating to the provision of such information or related decisions made based upon such information.