Please complete this application form if you are interested in becoming a CarePoint Clinic volunteer. By state requirements all in-clinic volunteers must be fully vaccinated.

Once you complete the form, click the Continue button at the bottom. Someone will contact you with next steps.

Name and address

First name:

Last name:

Title:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

OK to call me here

Cell phone:

OK to call me here

Email address:

Demographic Information

This is only used to help us get a better idea of the demographic make-up of our volunteers.

Date of birth:

Gender:

Education:

Volunteer Position Applying for

Please provide what volunteer position you are applying for

Availability

Please list your availability for volunteering

Current Employer and professional skills

Please provide us with your current employer information and length of employment. If not currently employed, enter "N/A" in the required (*) fields.

Please list professional skills that would be useful for clinic volunteering

Employer name:

First name:

Last name:

Title:

Street 1:

City:

State:

Zip:

Work phone:

OK to call here

Cell phone:

OK to call here

Email address:

Relationship:

Medical License Numbers

Medical volunteers must list current medical license numbers for verification. If you hold a medical certification, we can still utilize you as a front desk volunteer

Please include your NPI number

Providers

Do you have any active involvement with the Medical Board regarding your practice? Are there any practice limitations on your license right now?

Medical Malpractice Insurance

All medical professionals are required to have malpractice insurance that covers their volunteer work. Please indicate carrier and expiration date:

Free malpractice insurance for volunteers is available at

https://www.wahealthcareaccessalliance.org/volunteers.

How did you hear about CarePoint clinic?

First name:

Last name:

Street 1:

City:

State:

Zip:

Home phone:

Cell phone:

Email address:

Relationship:

CarePoint Clinic is a Christian Based Clinic

People come from many faiths to volunteer. Are you willing to work with people whose beliefs may be different than yours? If you are affiliated with a faith community, please provide name.

References

Please provide 2 references with at least one of these having knowledge of your professional experience.

1

2

First name:

Last name:

Title:

Street 1:

City:

State:

Zip:

Cell phone:

* OK to call here

Cell phone:

* OK to call here

Email address:

Relationship:

Criminal History

Have you ever been convicted of a crime? If yes, please explain.

CarePoint Clinic will run a background check prior to volunteering. Please provide your maiden name and/or any previous name you've used.

I agree/signature

I agree that the information I have provided may be verified by contacting persons or organizations named in this application. I hearby release and agree to hold harmless from liability any person or organization that provides information. I also agree to support CarePoint Clinic's Mission, values, policy and procedures and by clicking "I Agree", I recognize that I am putting myself under the authority of the CarePoint Board of Directors and leadership of the clinic.

I understand the CarePoint Clinic will conduct background checks and I agree to respond within the time indicated.

I Agree