Applicant Information

First name:

Last name:

Street 1:

City:

State:

* Zip: *

Cell phone:

Email address:

Spanish:

Demographic Information

You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.

Are you with a University or doing a Rotation?

Please note what University and program you are coming from and/or what clinic you will volunteering in?
(i.e. University of Utah - Medical Student with the University of Utah volunteering with the Neurology Clinic)

Emergency Contact

First name:

Last name:

Home phone:

Work phone:

Cell phone:

Email address:

Relationship:

Are you fluent in a language besides English?

Availability

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

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?

Electronic newsletters

Recruitment appeals

Volunteer Interests

Assignment Preference:

Family Medicine Attending [Family Medicine]

Family Medicine/ Residents [Family Medicine]

Family Medicine/Student [Family Medicine]

Meal Delivery [Q&I]

Weekend Intake [Q&I]

Weekend Meal Box [Q&I]

Why do you want to volunteer at Fourth Street Clinic?

Education

Acknowledgement

I understand and agree that submitting this application form does not automatically register me as a Fourth Street Clinic volunteer, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering.

By submitting this form, I attest that the information I have provided on the form is true and accurate.

I Agree