Volunteer Application Form

Please complete this application form if you are interested in becoming a Health and Hope Medical Outreach volunteer. Also don't forget to download the forms that need signed at the end of the application. Once you complete the form, click the submit button at the bottom.

Basic Information

First name:

Last name:

Middle name:

Street 1:

Street 2:

Street 3:

City:

State:

* Zip: *

Home phone:

Cell phone:

Email address:

First name:

Last name:

Home phone:

Cell phone:

Relationship:

Demographic Information

This information is optional. It is used only to provide volunteer demographics in grant applications.

Date of birth:

Age range:

Gender:

Education:

Major degree:

Minor degree:

Church:

Availability

The clinic is open only on Tuesdays from 5:00 pm to 8:00 pm .

Email Preferences

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email. We will send you only the emails you prefer to receive. Use the check boxes below to select the your email preferences.

What kinds of email would you like to receive?

Electronic newsletters

Recruitment appeals

Schedule reminders

Criminal Background

Have you been convicted of any criminal offense including, but not limited to, drugs, theft, or inflicting bodily harm, sexual or emotional injury? If yes, please explain.

Medical Volunteers

Professional Skills: MD/DO ( ) PA ( ) ARNP ( ) RN ( ) LPN ( ) CNA ( ) MA ( ) LAB TECH ( ) PHARMACY TECH ( )

School and year graduated:

Attach a copy of your license or certification, CV or Resume and COVID Vaccination Card.

Volunteer Release and Waiver of Liability Form

Open the Volunteer Forms link and print off these forms, sign them, and bring them with you to orientation.

Volunteer Forms <---Click Here

Coordinator Section- FOR OFFICE USE ONLY

HIPPA & Release Completion Date:__________________________

Background check___________________ WATCH Letter ________

Volgistics _______________ Phoenix _____________________

Medical sent to Credentialing Date:___________________

Resource: Sent to Spiritual Care Date:________________