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Volunteer Application

 

First Name *

Last Name *

Date of Birth *

Street Address *

City *

State *

Zip *

Home Phone *

Cell Phone

Work Phone

Email *

How did you hear about VIM?

Education

High School

Technical

Undergraduate School

Degree

Medical/Nursing

Specialty

Other Education

Medical License Number
(Please attach a copy of your medical license. Acceptable file formats: PDF, TIF and JPG.)

Driver's License Number
(Please attach a copy of your driver's license. Acceptable file formats: PDF, TIF and JPG.)

Volunteer Activity(s) desired (Check all that apply.) *

Special Skills and Availability
Languages spoken

Other skills/training

Hours available (Check all that apply) *

Please list any special needs that you have to ensure your safety and the safety of others.

In case of emergency
Person to contact

Relationship

Home phone

Cell phone

Work/Volunteer Experience
Please list any organizations that you have worked for, starting with the most recent.

Organization Dates Responsibilites

I attest that all information provided on this volunteer application form is to the best of my availability and believe true, correct and complete.

Signature *

Please note that an electronic signature is acceptable.

Date * (mm/dd/yyyy)

Grossmont Healthcare District Honors Healthcare Hero Volunteers

May 20, 2012 (East County Magazine) — Two volunteer physicians, two members of a community service club and a hospice volunteer were among this year’s recipients...

 

Ensuring care for uninsured

San Diego Union Tribune, November 2006 By Anne Krueger STAFF WRITER November 11, 2006 EL CAJON – Ken Bagley hadn’t visited a doctor’s office in decades....

 

Physicians plan debut of clinic for uninsured

San Diego Union Tribune, May 2005 By Anne Krueger STAFF WRITER May 2, 2005 EL CAJON – They’ve got the doctors, they’ve got the equipment and they’ve...