PO Box 216
Low Moor, VA 24457
(540) 862-6673
Volunteer Record
Welcome! We want
to keep accurate information on our volunteers. Please take a few minutes to fill out this form. This is a
printer friendly document so you may print the form, complete it and send it to
the address listed above.
Name:_____________________________________ Clinical License
#:_______________________
Address:___________________________________ Type of
License:_____________(Attach Copy)
(Street)
___________________________________ Expiration
Date:___________
(City,
State, Zip))
Granting
Board:__________________
Home
Phone:_______________________
Work
Phone: _______________________
E-mail
address:______________________ Date
of Birth:______________________
Are
you: [ ] Student Name
of school_________________
[ ] Employed
Place of employment (if applicable)_________________
[ ] Retired
Please
list the area(s) you are qualified to or might be interested in working:
______
Doctor ______ Physician
Assistant/ ______ Nurse ______ Medical Assistant
______
Receptionist ______ Medication Logger ______ Scheduler ______
Project Person
______
Newsletter ______Data Entry ______ Committee ______Fundraising
Do you
have any medical or psychological condition that may inhibit a specific type of
volunteer activity? Yes/No
Are you
up to date on vaccinations? yes/no
Have
you been vaccinated against Hepatitis B?
yes/no
Have
you had a PPD (TB) test in the last year?
yes/no
If you answered no to any of these questions please explain and note that the health department may have vaccinations and PPD testing available.
By signing the volunteer application I acknowledge that the Alleghany Highlands Free Clinic does not accept responsibility for illness or injury that occurs to an individual while volunteering at the Free Clinic.
Volunteer
Signature:______________________________ Date:____________________
________________________________________________________________________________________________
Staff
Notes: