Volunteer Application

    Volunteer Application

    First Name

    Last Name

    Date of Birth (MM/DD/YY)

    Address

    Address 2

    City

    State

    Zip

    Home Phone

    Cell Phone

    E-mail

    Contact Preference

    Educational Background

    School

    Dates Attended

    Major Course of Study/Degree

    Are You a Current Student?
    YesNo

    If yes, will you receive credit for your volunteer hours?
    YesNo

    Employment/Volunteer Background

    Dates Employeed

    Organization

    Type of Work

    Paid / Volunteer

    PaidVolunteer
    PaidVolunteer
    PaidVolunteer

    Current Professional Registration/License

    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

    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.
    Other

    We ask for a 6 month commitment for all volunteer roles

    What skills, training, or knowledge do you hope to utilize at CHC?

    Bilingual?
    YesNo

    If yes, which language(s)

    Why do you want to volunteer at CHC?

    Where did you hear about CHC?

    References

    Name

    Phone

    Relationship

    Availability

    Times

    Day(s)

    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.

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