Volunteer Application Form PERSONAL INFORMATION Name * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Date of Birth (required for background check) * MM DD YYYY Education * PROFESSIONAL AND VOLUNTEER EXPERIENCE Current Employer * Past Employers * Current or Past Volunteer Experience * Specialized Training or Skills * Physical Limitations * VOLUNTEERING INFORMATION Why are you interested in volunteering at Christ Community Free Clinic? * In accordance with the Washington State mandate, all patient-care volunteers must be fully vaccinated with the Covid vaccine by October 18, 2021. Please indicate whether you have been (or will be) vaccinated by that date. * Yes No Have you ever been convicted of a felony? * Yes No If yes, please explain. * How did you hear about the clinic? * REFERENCES Two references are required. Please do not use relatives (spouse, siblings, children, parents, cousins, aunts, uncles, or any other relatives). Name * First Name Last Name Relationship * Phone * (###) ### #### Best Time to Call * Name * First Name Last Name Relationship * Phone * (###) ### #### Best Time to Call * VOLUNTEER INTERESTS I am interested in volunteering in the following areas. * Please select all that apply Doctor / Physician Assistant / ARNP Nurse / Medical Assistant Dentist Hygienist Dental Assistant Social Worker Office Manager / Volunteer Coordinator Office Assistant / Medical Records Hospitality / Friendship / Host Interpreter Social Worker / Network Referral to Community Services Spiritual Support / Prayer Team Technology Support Pharmaceuticals Public Relations / Fundraising / Marketing Available for special one-time projects or events Other volunteer areas or languages spoken for interpreting services * VOLUNTEER REQUIREMENTS Please read and initial the following items required of all volunteers. I will maintain at all times patient confidentiality as required by HIPAA. * I will make every effort to keep my assigned schedule and will notify the Volunteer Coordinator if I am unable to report for duty. * I will abide by the established Christ Community Free Clinic rules and regulations. * I will be willing to commit to a period of six months of service. * I agree to be bound by the Articles, Bylaws, and Policies of Christ Community Free Clinic, and refrain from conduct in violation of CCFC's Mission / Vision or Statement of Faith. * I understand that a Criminal Background check (RCW 10.97) will be done prior to volunteering. * I certify that the information given on this application is true and complete. * Electronic Typed Signature * Date * MM DD YYYY Thank you for submitting the Volunteer Application for Christ Community Free Clinic. Our Volunteer Coordinator will contact you soon.