Name and Address


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.


For Clinical Volunteers Only

Please only complete this section if you are applying to volunteer with us as a physician, nurse practitioner, registered nurse,EMT, or in another clinical role. If you have any questions please contact jsmith@vim-jax.org.


Employer/Volunteering Information

Please complete this section if you are currently employed or volunteering with an organization. Please leave blank if you are not currently working or volunteering with an organization.


Emergency Contact Information


Reference

Please provide one reference.


Additional Relevant Experience/Skills


Availability

Please indicate the days and times you are usually available to volunteer. If you are available on a sporadic basis please indicate that in the field provided with any relevant details. Please note that morning shift is from 9am-1pm and afternoon shift is from 1-5pm. We are only open from 9am-12pm on Saturdays.


Length of Commitment

Please use the field below to share the length of time (6 months, a year, etc) that you will be able to commit to volunteering.


Goals

Please share what your goals for volunteering are below. Examples: To learn more the medical field while in the process of applying to medical school, to give back to the community, to remain active.


I Agree

I understand and agree that submitting this application form does not automatically register me as a Volunteers In Medicine Jacksonville 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.