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:
Choose
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
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Zip:
*
Primary phone:
*
Day/Work phone:
Cell phone:
Email address:
*
Date of birth:
Month
Jan
Feb
Mar
Apr
May
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Jul
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Oct
Nov
Dec
Day
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2022
2021
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1922
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1920
1919
1918
1917
*
Current/Past Employment
Please fill out current or most recent employment below.
Employment Status:
Choose
Employed
Unemployed
*
Employer name:
First name:
Last name:
Street 1:
Street 2:
City:
State:
Choose
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
Primary phone:
OK to call here
Email address:
Education
Education:
Choose
Associate degree
College degree
Doctoral degree
High school diploma
Masters degree
Some college
Trade/Vocational school
*
Current Student Status:
Choose
College
Graduate School
Graduated
High School
Pre Dental
Pre Med
Technical School
Volunteer Experience(s)
Specifically working with vulnerable populations.
*
Skills:
Administrative Skills
Computer Knowledge
Customer Service Experience
Data entry
Filing
Graphic Design
Strong Communication Skills
Telephone
Website
Patient Population Experience:
Elderly Adults
Homeless Adults 23+
Homeless Youth 12-23
Infectious Diseases
Low-Income Families
Maternity/Infants
No Experience
STD/HIV Positive
Youth
Motivational Statement
Why do you want to volunteer for Neighborcare Health?
How did you learn about our volunteer program?
Availability
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Morning 7 am-12 pm:
Afternoon 12-5 pm:
Evening 5-10 pm:
Available Start Date:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
I would like to serve up to:
Frequency:
Choose
Time/Month
Times/Week
Times/Year
Non English Language(s)
Clinics
*
Site Preference:
1st choice:
Choose
Neighborcare Health Administration
Neighborcare Health at 45th Street
Neighborcare Health at Ballard
Neighborcare Health at Central District
Neighborcare Health at Columbia City
Neighborcare Health at Georgetown
Neighborcare Health at High Point
Neighborcare Health at Lake City
Neighborcare Health at Meridian
Neighborcare Health at Pike Place Market
Neighborcare Health at Rainier Beach
Neighborcare Health at Vashon
Neighborcare Health School-Based Health Centers
Neighborcare Health Youth Clinic at 45th Street
2nd choice:
Choose
Neighborcare Health Administration
Neighborcare Health at 45th Street
Neighborcare Health at Ballard
Neighborcare Health at Central District
Neighborcare Health at Columbia City
Neighborcare Health at Georgetown
Neighborcare Health at High Point
Neighborcare Health at Lake City
Neighborcare Health at Meridian
Neighborcare Health at Pike Place Market
Neighborcare Health at Rainier Beach
Neighborcare Health at Vashon
Neighborcare Health School-Based Health Centers
Neighborcare Health Youth Clinic at 45th Street
3rd choice:
Choose
Neighborcare Health Administration
Neighborcare Health at 45th Street
Neighborcare Health at Ballard
Neighborcare Health at Central District
Neighborcare Health at Columbia City
Neighborcare Health at Georgetown
Neighborcare Health at High Point
Neighborcare Health at Lake City
Neighborcare Health at Meridian
Neighborcare Health at Pike Place Market
Neighborcare Health at Rainier Beach
Neighborcare Health at Vashon
Neighborcare Health School-Based Health Centers
Neighborcare Health Youth Clinic at 45th Street
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:
*
First name:
*
Last name:
*
Last name:
*
Middle name:
Middle name:
Title:
Choose
Dr.
Mr.
Mrs.
Ms.
Title:
Choose
Dr.
Mr.
Mrs.
Ms.
Street 1:
Street 1:
Street 2:
Street 2:
City:
City:
State:
Choose
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
State:
Choose
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
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:
*
Email address:
*
Relationship:
Choose
Brother
Co-worker
Daughter
Father
Friend
In-Law
Instructor
Mother
Neighbor
Partner
Sister
Son
Spouse
Supervisor
*
Relationship:
Choose
Brother
Co-worker
Daughter
Father
Friend
In-Law
Instructor
Mother
Neighbor
Partner
Sister
Son
Spouse
Supervisor
*
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
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