Volunteeer Application

Thank you for your interest in volunteering at the Free Medical Clinic / Dick Parrott Free Dental Clinic.

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


Which volunteer positions are you interested in?

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


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

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

Tell us how you heard about the Free Medical Clinic, and why you would like to be a volunteer here.

What can you contribute as a volunteer at the Free Medical Clinic? What do you hope to gain out of your volunteer experience here?

What do you like to do in your spare time? Anything else you’d like to share with us?

Please detail your availability. When can you start volunteering? What length of time can you commit to volunteering? Do you have daytime or evening availability, or both?


Please list two professional references for us to contact.


Name
 Phone
Institutional Affiliation
 Email


Name
 Phone
Institutional Affiliation
 Email


PLEASE NOTE:

  • You can expect to hear from us within 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.

  • When you click "Send," your e-mail program will create a message to send your answers to us. Please click the "Send" button only once. After the e-mail message is created and sent, you may close this window or return to the home page.

Thank you again for your interest!