Date of Birth (MM/DD/YY)
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonMarylandMassachusettsMichiganMinnesotaMississippiMissouriPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOther (non-US)
Current Professional Registration/License
Are you currently employed as a medical provider?
If Yes, where?
Current hospital affiliations:
Have you ever been convicted of a felony?
If Yes, please explain
Please provide all medical information we should know (allergies,special medications, instructions, &/or conditions)
If yes, which language(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.
Comments are closed.