Thank you for your interest in joining the volunteer team at the Free Clinic of SW Washington. This application is for HEALTH PROFESSIONALS whose credentials are regional, national, or otherwise not with the WA State Dept. of Health. Please provide your information as completely as possible. Health Professionals that have out-of-state licenses are required to fill out a WA state attestation stating that they can only volunteer up to 30 days in a calendar year for the Free Clinic.


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
If you are not employed, please list your last employer and last date worked.


Credentials
Please select (or describe) your license type, the state in which you are licensed and/or provide the contact information for the credential verifying agency or national organization.


Liability Insurance
The Free Clinic insurance policy covers all volunteers with the EXCEPTION of Dentists and Physicians. Washington Healthcare Access Alliance (WHAA), provides free malpractice insurance for all health professional volunteers & helps with the cost of licensing for those who only use their license to volunteer. If you need or would prefer to have separate insurance, please go to the WHAA website https://www.wahealthcareaccessalliance.org/ or contact the Volunteer Office at 360.313.1389.


Assignment - Availability - Scheduling Preferences
Please select your preferred assignment and the days/times which you are generally available to volunteer. 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 the month). If you are a specialist, will you provide care only in your specialty? Please use the notes section for additional details.


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 (official) 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
In case of emergency, who should we contact on your behalf?


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 a criminal background check.

CRIMINAL BACKGROUND CHECK
As of July 1st, 2010, any new volunteer applicants must consent to, and pass, a criminal background investigation before being accepted as Free Clinic volunteer. The Vancouver School District, a Free Clinic partner, and will implement these checks for the Free Clinic, according to their own policy and procedure guidelines. Results of these checks will be reviewed by the Volunteer Manager for a final determination of volunteer suitability.

OREGON RESIDENTS
A $10 processing fee will be collected prior to screening of applicants from Oregon in order to access the Oregon State Criminal Background Check database.

EXCEPTIONS
Health Professionals who are licensed in Washington State are exempt from this procedure because the state conducts a criminal background check before issuing a license.


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.