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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