Provider Application

Provider Application

First Name

Last Name

Date of Birth (MM/DD/YY)

Address

Address 2

City

State

Zip

Home Phone

Cell Phone

E-mail

Current Professional Registration/License

Are you currently employed as a medical provider?
YesNo

If Yes, where?

Current hospital affiliations:

Have you ever been convicted of a felony?
YesNo

If Yes, please explain

Please provide all medical information we should know (allergies,special medications, instructions, &/or conditions)

Emergency Contact

Phone

Bilingual?
YesNo

If yes, which language(s)

Availability

Times

Day(s)

How often per week/month?

How long can you commit to this service?

When are you available to start?

Where did you hear about Catherine's Health Center?

As a volunteer medical provider, we request a copy of the following documents:
- Your current license(s)
- Your Curriculum Vitae
- A valid driver's license or photo ID
- Documentation of current TB test, if available
- Current malpractice insurance information, if available

At Catherine's Health Center, it is our mission to provide health education, screening, and primary care medical services to low income, underinsured, and medically underserved residents of Grand Rapids, MI. As a volunteer at CHC, I will be required to follow all personnel policies and rules of the organization.

I have completed this volunteer application and hereby declare the information provided to be accurate and complete to the best of my knowledge.

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