Volunteer Application

Please complete this application form if you are interested in becoming a Neighborcare Health volunteer. Once you complete the form, click the submit button at the bottom. For any questions, please contact volunteers@neighborcare.org

Contact Information

First name:

Last name:

Middle name:

Street Address:

City:

State:

* Zip: *

Primary phone:

Day/Work phone:

Cell phone:

Email address:

Date of birth:

Current/Past Employment

Please fill out current or most recent employment below.

Employment Status:

Employer name:

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Primary phone:

OK to call here

Email address:

Education

Education:

Current Student Status:

Volunteer Experience(s)

Specifically working with vulnerable populations.

Motivational Statement

Why do you want to volunteer for Neighborcare Health?

How did you learn about our volunteer program?

Availability

Non English Language(s)

Clinics

* Site Preference:

1st choice:

2nd choice:

3rd choice:

References

Please provide us with at least 2 people we may contact as references for you. Please notify them that we will be reaching out and that they should respond within two weeks.

1

2

First name:

Last name:

Middle name:

Title:

Street 1:

Street 2:

City:

State:

Zip:

Primary phone:

* OK to call here

Primary phone:

* OK to call here

Day/Work phone:

OK to call here

Day/Work phone:

OK to call here

Cell phone:

OK to call here

Cell phone:

OK to call here

Email address:

Relationship:

Agreement

I certify that the information contained in this application is true, correct and complete to the best of my knowledge. I understand that the consideration of this application and continuation of any subsequent volunteer placement depend upon the true and accurate representation of the facts as stated or implied herein. In addition, I hereby authorize Neighborcare Health to make inquiries regarding my education, work, experiences and references, unless otherwise stated. I hereby release to the fullest extent allowed by law all parties and persons associated with such inquiries from liability in connection with information they request or give. The undersigned acknowledges and agrees that he/she is not obligated if called upon to perform the volunteer placement. If accepted as a volunteer, the undersigned agrees to abide by the policies, rules and regulations of Neighborcare Health and the Volunteer Program.

I Agree