Thank you for your interest in joining the volunteer team at the Free Clinic of SW Washington. This application is for HEALTH PROFESSIONALS who are LICENSED with the WA State Department of Health. Please provide your information as completely as possible.


After submitting your application, please allow 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.


Personal Information

Please provide your full legal name so that we may verify your professional credentials online.



Employment


Licensure

Credentialing is completed on the Washington State DOH website. If your license is pending, under a different name, or there is something else we should know before verifying the license, please detail below.



LIABILITY INSURANCE

The Free Clinic insurance policy covers all volunteers with the EXCEPTION of Dentists and Physicians. For these professionals, notifying your own carrier that you are volunteering is usually enough. However, should your own policy specifically exclude volunteer service, Washington Healthcare Access Alliance (WHAA) provides free malpractice insurance for volunteers & helps with the cost of licensing for volunteer providers, as well as for those who only use their WA license to volunteer. Please go to the WHAA website https://www.wahealthcareaccessalliance.org/ or contact the Volunteer Office for more information at 360.313.1389.



Assignment, Availability & Scheduling Preferences

Please select the days/times which you are usually available to volunteer, then select your preferred job, or an open job. If your preferred job is not open, we will place you on a wait list for the next opening. Our Basic Care clinic hours are: Mon, Wed, Thur-9AM to 12PM & 1PM to 4pm, Tue-1PM to 4PM & 6PM to 9PM, Fri-9AM to 12PM (NO clinic first Friday of each month).



Affiliation / Group Volunteers

Some volunteers are associated with a particular service group (Friends of the Free Clinic) or service day (Kaiser MLK Day). Please let us know if you are, or if you would like to start a group effort from your clinic.



Reference / ID Verification

Note: A government Photo ID is required before beginning volunteer service.


Please list one professional and one character reference below:



Skills, Experience and Motivations

Please tell us a little about yourself, why you wish to volunteer with Free Clinic, any specific skills you have, and note any relevant volunteer experience.



Emergency Contact Information


Full Disclosure

Please disclose any criminal convictions and/or any action(s) against your professional license and explain with the text field below. This disclosure does not automatically preclude volunteer service here but must be reviewed by FCSW. By submitting this application you are giving permission for FCSW to conduct credential verification.



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.



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.


LIABILITY INSURANCE Free Clinic insurance specifically EXCLUDES malpractice for PHYSICIANS and DENTISTS. These professionals should notify their insurance policy holder they will be volunteering their professional services at the Free Clinic. Should your policy holder specifically exclude your volunteer service, you may register with AHEC for free liability insurance. (see www.freeclinics.org/volunteer/insurance)


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.