Volunteeer Application

First name
 Last name
Address/PO Box
Apt. or unit number
City
State
Zip code
Email
Phone number (home)
Phone number (work)
Language Proficiencies


Which volunteer positions are you interested in?

Receptionist
Patient guide
Phlebotomist
Lab technician
Examiner (e.g. PA-C, ARNP, M3, M4, MSTP)
Pharmacist
Pharmacist technician/Pharmacy student
Physician
Dentist/Dental Hygienist/Dental Assistant
Daytime volunteer
One-time volunteer
Interpreter (Spanish)
Other (e.g. Dietician, Physcial Therapist, Chiropractor, etc.)


Please describe any medical training, experience or skills that would help you perform volunteer duties at the Free Medical Clinic.

Please describe other volunteer experiences you have had, including your responsibilities and total time commitment.

Please describe any work or life experiences where you have interacted with diverse populations.

Please detail your availability (e.g. when can you start volunteering? for what length of time can you commit to volunteering? do you have daytime or evening availability, or both?)


Please give two professional references for us to contact.

Name
 Phone
Institutional Affiliation
 Email
Name
 Phone
Institutional Affiliation
 Email


PLEASE NOTE:
You can expect a phone call from FMC staff 7-10 working days after the receipt of your online application. If you haven't heard from us within 10 working days, please call us at (319)-337-4459.