Please complete this application form if you are interested in volunteering with Bethesda Mission in our Medical or Dental Clinic. Once you complete the form, please click the Continue button at the bottom.

Contact Information

First name:

Last name:

Title:

Street Address:

City:

State:

* Zip: *

Best Contact phone:

* OK to call me here

Work phone:

OK to call me here

Email address:

Personal History

Why do you want to volunteer with us?

Please tell us how you heard about Bethesda Mission, and why you'd like to volunteer with us.

Where would you like to volunteer?

Please indicate if you are looking to volunteer in the Medical or Dental Clinic.

Is your license under review?

Please answer "yes" or "no." If yes, please explain in detail.

Emergency Contact

Please include a name and phone number of the person we should contact in the unlikely case of an emergency.

First name:

Last name:

Cell phone:

References

Please include the names and phone numbers of two references whom we may contact with any questions.

I Agree

I understand and agree that submitting this application form does not automatically register me as a Bethesda Mission volunteer, and that there may be certain qualifications that I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering.

I certify that to the best of my knowledge and belief, all of the information I have provided on this application is true, correct, complete, and made in good faith. I understand that a false statement on any part of this application may be the basis for disqualifying me as a volunteer at Bethesda Mission, or for discontinuing my services after I begin volunteering.

I consent to the release of information by employers, law enforcement agencies and other individuals and organizations to designated representatives of Bethesda Mission.

I acknowledge that I received and read the Confidentiality Policy and understand or have sought understanding of its content, and I recognize that it is my responsibility to abide by all rules contained in the policy.

As a volunteer, I may have access to confidential and private information in various forms, such as written, electronic, oral, overheard, or observed or any other source, and I am required to maintain this information in a confidential manner. The unauthorized access to, modification, deletion or disclosure of confidential or private information may compromise the integrity of the Mission's written or electronic records and violates individual rights of confidentiality and privacy. I further understand that Bethesda Mission will not tolerate unauthorized disclosure of confidential or private information and will not hesitate to dismiss any volunteer who violates this policy.

I acknowledge and agree to the requirements of the Confidentiality Policy.

I Agree