Please complete this application form if you are interested in becoming a Mosaic Medical volunteer. Once you complete the form, click the Continue button at the bottom.

Name and address

First name:

Last name:

Title:

Street 1:

Street 2:

Street 3:

City:

State:

* Zip: *

Work phone:

OK to call me here

Cell phone:

OK to call me here

Email address:

Please enter your birth date in the comment field.

Availability

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

My availability is:

From:

to:

I would like to serve up to:

hours:

Email Preferences

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email, however will not send you any email you prefer not to receive. Use the checkboxes below to select the kinds of email you would like to receive from us.

What kinds of email would you like to receive?

Mosaic Updates

Stay up to date with Mosaic Medical by subscribing to our newsletter.

Volunteer Opportunities

Opt in if you'd like to stay in the loop on new volunteer opportunities with Mosaic Medical.

Background

Please indicate if you have volunteered with Mosaic Medical in the past in any capacity, including at the Mosaic/ DCHS vaccination clinics. If you have never volunteered with Mosaic Medical, please disregard this section.

Vic Tab

Please create a unique log-in to access your volunteer information and assignments with Mosaic Medical in the future.

Please enter a password that:

Is between 8 and 30 characters long
Contains both letters and numbers.
Contains a combination of both uppercase and lower case letters.

Password:

Confirm password:

Allow other volunteers to see when I am scheduled

Additional requirements

Due to an Oregon state mandate, all active healthcare volunteers must be vaccinated or be willing to present proof of a weekly COVID-19 test. Some volunteer positions require additional training, a minimum age, and/ or background checks. These details will be designated on the position description if applicable.
Please mark "I Agree' if you agree to providing any additional necessary information, including proof of vaccination or weekly COVID test, undergoing position specific training and/or background checks as required for specific positions.

I Agree