Thank you for your interest in volunteering at Safe Harbor Free Clinic.  By submitting this form, applicants agree to a background check by the Washington State Patrol and other licensure/certification checks as needed. Once you complete the form, click the submit button at the bottom. We will respond via email with additional information and training dates within a few days (up to two weeks). PLEASE BE SURE TO ADD safeharborfreeclinic.org TO YOUR SAFE SENDER LIST, to avoid our response going to your junk mail folder.


Name & Address


Employer Reference


Personal Reference


- ALL VOLUNTEERS -

In accordance with the Washington State mandate, all our patient-care volunteers must be fully vaccinated with the Covid vaccine by October 18, 2021.  Please use YES or NO to indicate whether or not you have been fully vaccinated..



- MEDICAL PROVIDERS -

Please submit your DEA & NPI numbers, 

as well as education information (Institute, Degree, Date, and Certification).  

This is required for the NPDB background check.



- MEDICAL VOLUNTEERS -

PLEASE PROVIDE YOUR MEDICAL LICENSE # and EXPIRATION DATE



- MEDICAL STUDENTS -

When will you finish your schooling? Do you currently have a medical license at any level? If so, please indicate:



- INTERPRETER -

If you are willing to work as an interpreter, please indicate which language(s) you speak.



Certifications, Skills & Experience

Please list non-medical skills, training, and/or experience you have. If applicable, include any medical certifications.



Medical Volunteers - Malpractice

If a medical professional, do you have any past or pending malpractice suits against you? If yes, indicate what are the details and outcome?



Have you been convicted of a criminal offense?

Have you within the past 7 years been convicted of any criminal offense involving drugs, theft, or inflicting bodily, sexual or emotional injury? If yes, indicate the nature of the offense, date, court & disposition.



Ceritification

By submitting this form you certify the information in this application as true and complete to the best of your knowledge.



I agree

By submitting this application, I authorize Safe Harbor Free Clinic and its representatives to investigate and verify any and all of the information contained in this volunteer application, including a criminal background check, education verification, licensure verification and National Provider Data Base check.