Volunteer Opportunities Personal Information Name * First Name Last Name Date of Birth * MM DD YYYY Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Volunteer Services Please select each area in which you are licensed or have an interest in volunteering * *Health Care Professionals must be licensed and/or certified in the state of Texas to practice at the Clinic. Please provide the following information Physician (MD,DO) Nurse Practitioner (FNP, PNP) Physician Assistant (PA) Nurse (RN, LVN, CNA) Pharmacist (RPh) Pharmacy Technician Certified Medical Assistant (CMA) Spanish Interpreter Intern Patient Registration/Screener Daytime Projects (Clerical) Other If "Other" selected above, please specifiy Occupation / Specialty Medical License # / Certification Expiration Date MM DD YYYY Last four (4) digits of Social Security Number Health Care Professionals: Do you have privileges at any local hospital(s)? Yes No If "Yes" to the above, which one? Scheduling Preferences Preferred Day * Select all that apply. Monday Tuesday Morning Clinic Thursday Preferred Frequency * Once per Month Twice per Month Language Skills - Fluent * Select all that apply. English Spanish Chinese Japanese Korean Other If "Other" to above, please specify Language Skill - Conversational * Select all that apply. English Spanish Chinese Japanese Korean Other If "Other" to above, please specify Volunteer Experience Have you volunteered elsewhere? If so, where? Please provide details. * What are reason(s) for wanting to volunteer at the Greater Killeen Community Clinic? * Text What do you hope to achieve from your volunteer experience? * How did you hear about Greater Killeen Community Clinic? * References Reference 1 First Name & Last Name * First Name Last Name Reference 2 Phone Number * (###) ### #### Reference 2 First Name & Last Name * First Name Last Name Reference 2 Phone Number * (###) ### #### Conviction Record Statement Have you ever been convicted of, or received deferred adjudication for, a crime? * Yes No If "Yes" to the above, please explain Agreement I authorize any inquiry to be made on any information contained in this application if I am considered for volunteer placement which could include a background check. I agree to all terms of the Volunteer Orientation and Standards, including Standards of Dress and Privacy Policies. I am willing to serve at a minimum of six (6) months after my on the job training. I understand I will serve two (2) three (3) hour shifts a month unless my duty assignment calls for a different schedule. I understand that all files and records maintained by the Greater Killeen Free Clinic are privileged and confidential. Any and all information that I may have access to may not be released or communicated to others unless authorized by the Executive Director or staff member who has also been authorized by the Executive Director to make that determination. I understand that I will be expected to treat all patients, volunteers and staff with respect. I understand and consent that any photos or video taken of me while at the Clinic can be used for Clinic purposes. I acknowledge my understanding of the conditions of my voluntary service for the Greater Killeen Free Clinic and acknowledge and understand that I must conform to the rules and regulations of the Greater Killeen Free Clinic to the best of my ability or my voluntary services may be terminated. * I agree Volunteer First Name & Last Name * First Name Last Name Today's Date * MM DD YYYY Thank you!
