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Volunteer Application
Volunteer Application Form
Date
MM slash DD slash YYYY
Name
(Required)
First
Last
Date of birth
(Required)
MM slash DD slash YYYY
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(Required)
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Email
(Required)
Preferred Method of Contact
Phone
Email
Text
Other
Emergency Contact Name
Relationship
Phone
Have you ever been a Waukesha Free Clinic patients or received services from WFC?
Yes
No
Are you related to a patient from the Waukesha Free Clinic?
Yes
No
Have you ever been convicted of a criminal offense?
Yes
No
If yes, please provide an explanation of the offense(s) and the date(s) in which it/they occured. Applicants will not be denied because of a conviction for an offense which is not substantially related to the circumstances of the volunteer position sought.
Have you previously worked in a healthcare setting?
Yes
No
If yes, when?
How did you hear about the Waukesha Free Clinic?
Are there any accomodations that we need to make to facilitate your participation?
Area of Volunteer Interest
Medical Volunteer Positions (MUST BE LICENSED)
Physician
Nurse Practitioner
Psychiatrist
Physician Assistant
Counselor
Registered Nurse
Pharmacist
Medical Assistant
Chiropractor
Physical Therapist
Area of Volunteer Interest
Non-Medical
Clerical
Office Assistant
Screener
Data Entry
Receptionist
Patient Outreach
Interpreter
Fundraising/Marketing
Availability
(Required)
Please let us know if you would prefer to help with:
Medical Clinic
Office
Both
Monday
Morning
Afternoon
Evening
Tuesday
Morning
Afternoon
Evening
Wednesday
Morning
Afternoon
Evening
Thursday
Morning
Afternoon
Evening
Friday
Morning
Afternoon
Evening
How often can you volunteer?
(Required)
Daily
Weekly
Monthly
Other
What length of commitment are you willing to make?
(Required)
Long-term
One year
Six Months
Semester
Other
Are you fully vaccinated against COVID-19?
(Required)
Yes
No
Authorization and Release
(Required)
I certify that the information I have provided is complete and accurate to the best of my knowledge. I understand that:
- An agent of Waukesha Free Clinic will be checking my background with the appropriate public authorities,
- If I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in immediate dismissal.
- Completing the application process does not guarantee acceptance as a volunteer.
I accept the terms
Number
Date
MM slash DD slash YYYY
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