Volunteer Application Form

Please complete this application form if you are interested in becoming a Snake River Community Clinic 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:

City:

State:

Zip: *

Home phone:

OK to call me here

Work phone:

OK to call me here

Cell phone:

* OK to call me here

Email address:

Demographic Information

The following information is optional. The information you provide below is used only to help us get a better idea of the demographic make-up of our volunteers.

Date of birth:

* (year optional)

Education:

Major degree:

Minor degree:

School:

College:

Insurance company:

Employer name:

First name:

Last name:

Title:

Street 1:

Street 2:

Street 3:

City:

State:

Zip:

Work phone:

OK to call here

Availability

Please indicate the days and times you are usually available to volunteer. Available times are as follows: Mondays and Wednesdays 10:00 AM - 4:00 PM, and Thursdays 5:00 PM - 8:00 PM. Minimum shift is 2 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.

Volunteer Position Preference

Volunteer positions you are applying for (or general area of preference).

Assignment Preference:

Dental [Volunteer Services]

Lab [Volunteer Services]

Medical Students [Volunteer Services]

Nursing [Volunteer Services]

Pharmacy [Volunteer Services]

Provider [Volunteer Services]

Reception [Volunteer Services]

Scribe [Volunteer Services]

Social Services [Volunteer Services]

Reference

Please provide a character/work reference.

First name:

Last name:

Title:

City:

State:

Zip:

Home phone:

OK to call here

Work phone:

OK to call here

Relationship:

Contacted:

Verified:

Professional License/Certificate

Please provide your Professional License Number(s) and or Certification (if applicable). You will need to bring your license with you so that we may include a copy in your file or upload it into our volunteer database.

Spoken Languages

Please list any languages you speak, other than English.

Sign Language

Please indicate whether you are proficient in sign language.

Pronoun Preference

Please indicate pronoun preference.

Gender:

Statement of Commitment

Welcome to Snake River Community Clinic. As a volunteer, you are a vital resource in helping the Clinic continue to provide free health care. This contract outlines your responsibilities as a volunteer. It also describes what we expect from you. Thank you for your valuable time and skills.

Volunteer Responsibilities:

Maintain a minimum three-month commitment to your current volunteer position.
Arrive on time for all shifts. If you must be late or miss a shift, please call and let us know as early as possible. The office phone number is: (208)743-5899.
Attend trainings and/or orientations as required.
Perform all responsibilities as listed in your job description.
Follow all clinic policies and procedures.

SRCC Responsibilities

Provide training and supervision to all volunteers.
Provide a safe and enriching environment for all volunteers.

I Agree

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