Date of Birth (MM/DD/YY)
Are You a Current Student?
If yes, will you receive credit for your volunteer hours?
Current Professional Registration/License
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)
What type of work would you like to perform at CHC? Please check all that apply
ClericalMedical RecordsR.N.CleaningAdministrativeComputer/Data EntryL.P.N.MaintenanceReceptionistMedication AssistanceM.A.Fundraising/DevelopmentMailingsCommunity ProgramsEventsWomen's Heath AdvocateMarketing/P.R.
We ask for a 6 month commitment for all volunteer roles
What skills, training, or knowledge do you hope to utilize at CHC?
If yes, which language(s)
Why do you want to volunteer at CHC?
Where did you hear about CHC?
How often per week/month?
How long can you commit to this service?
When are you available to start?
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.