SET Family Medical Clinic - Homeless Clinic - Volunteer Application

Please complete this application form if you are interested in becoming a SET Homeless Clinic volunteer at Marian House. Once you complete the form, click the submit button at the bottom. A background investigation authorization form will need to be completed prior to proceeding to the next step.

Once the application is completed, please contact Leah Aragon leaharagon@centura.org 719-776-8861, to continue the onboarding process.

Personal Information

First name:

Last name:

Middle name:

Title:

Street 1:

Street 2:

Street 3:

City:

State:

* Zip: *

Home phone:

* OK to call me here

Work phone:

* OK to call me here

Cell phone:

Email address:

How did you hear about SET?:

Date of birth:

* (year optional)

Gender:

What kinds of email would you like to receive?

Employment and Education

Degree:

Employer Name:

Professional License and Certification

Professional License #:

Expiration Date:

Emergency Contact

First name:

Last name:

Title:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

Work phone:

Cell phone:

Relationship:

Area's of Interest

* Assignment Preference:

Volunteer EMT/ Paramedic [SET Family Medical Clinics\SET Homeless Clinic at Marian House: Mon-Fri (11:30AM - 1PM)]

Volunteer Intake Coordinator [SET Family Medical Clinics\SET Homeless Clinic at Marian House: Mon-Fri (11:30AM - 1PM)]

Volunteer Nurse Practitioner (NP) [SET Family Medical Clinics\SET Homeless Clinic at Marian House: Mon-Fri (11:30AM - 1PM)]

Volunteer Physician (MD, DO) [SET Family Medical Clinics\SET Homeless Clinic at Marian House: Mon-Fri (11:30AM - 1PM)]

Volunteer Physician Assistant (PA) [SET Family Medical Clinics\SET Homeless Clinic at Marian House: Mon-Fri (11:30AM - 1PM)]

Volunteer Registered Nurse (RN) [SET Family Medical Clinics\SET Homeless Clinic at Marian House: Mon-Fri (11:30AM - 1PM)]

Times

Assignment

Informed Consent, Release & Confidentiality Stmt

I, offer to volunteer my services to SET Family Medical Clinics. I do realize that I will not be paid in any way. I understand that this agreement can be cancelled at any time by SET or by me.

I release SET Family Medical Clinics, its employees, their heirs, agents, instructors and volunteers from any liability for loss or injury to my person or property that may occur due to negligence or other acts of omissions. This release applies to any losses or injuries that may occur as a result of, or during my participation in volunteer services.

I understand that any confidential information I might overhear must remain confidential, I understand that while acting as a volunteer of SET, I must observe the rules and regulations that apply to my volunteer position and that these rules are outlined in the job description.

I Agree