Volunteer Form - Community Health Care Clinic

Volunteer & Internship Form

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Personal Information

Full Name(Required)

Full Name

Your Address

Street Address Address Line 2 City State ZIP Code

Your Email Address(Required)

Enter Email Confirm Email

Your Phone(Required)

Fluent Languages

Rate Level of Fluency

for example - 1. speak it at home, ready to translate 2. translated but would need to brush up on medical terms 3. taken years of high school/college but never translated

Education

Current Student(Required)

Yes

School

Major

Minor

Work

Are you currently employed?(Required)

Yes

Status

Full Time

Part Time

Retired

Occupation (or previous if Retired)(Required)

Availability

Monday

Tuesday

Wednesday

Thursday

Questions

How did you hear about CHCC?(Required)

List any training, professional licenses and/or certifications you may hold.

In a brief paragraph, explain what interests you about CHCC and why you would like to volunteer here.

What skills can you contribute to the Clinic?

List the specific volunteer role(s) that interest you (in order of preference).