Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Primary phone
*
(###)
###
####
Secondary phone
(###)
###
####
Areas of interest
*
In case we cannot accommodate your first choice, please select all that apply
Other
Healthcare Provider position being applied for
Please note: These positions require a valid medical license.
Are you over the age of 18?
*
Name
*
Phone
Relationship
Do you have any physical or cognitive limitations that may prevent you from performing certain tasks?
*
If yes, please describe
Highest level of education completed
Degree
Medical License Number
Medical License Exp. Date
DEA Number (if applicable)
Current Employer (if applicable)
Position/Title
Date of Hire
Please list any special skills, hobbies and/or training
Languages spoken
Please list specific days and hours you are available to volunteer
Note availability each day with times
Some positions at VIM require a one year commitment. Are you able to make this commitment?
All VIM volunteers must pass a background check. Are you willing to undergo a background check?
Do you have a valid driver's license?
Do you have auto insurance?
Previous volunteer experience that would prepare you for our clinic
Do you have prior experience working in a no-/low-cost medical clinic?
If yes, please provide clinic name, location, duties, and date(s)
Please share a little about why you want to volunteer with VIM and what are you hoping to gain from your volunteer experience.
Reference 1
Name / Organization / Relationship / Phone / Length of relationship
Reference 2
Name / Organization / Relationship / Phone / Length of relationship
Reference 3
Name / Organization / Relationship / Phone / Length of relationship
Clinical license in any jurisdiction
Other professional license
DEA certificate
Privileges on any hospital medical staff
Membership on any hospital medical staff
Board certification
Any other professional sanction
Have you ever been subject to any disciplinary action in any health care organization or is any action currently pending?
Are you under any special monitoring requirements?
Have you ever resigned or taken leave of absence in order to avoid possible revocation, suspension, or reduction of privileges at any hospital or clinic?
Have you had any malpractice cases filed against you?
If you answered yes to any of the questions above, please give a brief explanation here
11. SIGNATURE (Please read the following carefully before signing this application.)
*
I understand that this is an application for, not a commitment or promise of, volunteer opportunity. By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application or in the interview process may result in my immediate dismissal. It is the policy of VIM to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.
Date
*
