Please complete this application form if you are interested in becoming a CarePoint Clinic volunteer.

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 and Availability

Please provide what volunteer position you are applying for along with the days of the week that you are available (Monday - Saturday), and shift availability (Morning, Afternoon, Evening).

Employment

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

Please also note amount of experience you have in the volunteer postion you are applying for. (For example - if an RN, how long have you worked in that role.)

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:

Professional Skills/Medical License Numbers

All volunteers should list professional skills and medical volunteers must list medical license numbers for verification.

How did you hear about CarePoint clinic?

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.

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:

Home phone:

* OK to call here

Home phone:

* OK to call here

Cell phone:

* OK to call here

Cell phone:

* OK to call here

Email address:

Relationship:

Emergency Contact

First name:

Last name:

Street 1:

City:

State:

Zip:

Home phone:

Cell phone:

Email address:

Relationship:

Criminal History

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

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