General Volunteer Application Form

Please complete the following required information in order to be a Volunteer Health Professional sponsored for deeming by the Free Access Health Clinic.

Individual Details


Address in Vermont
Phone (Home)
Phone (Work)
Phone (Cell)
Fax (If Any)
Days and Hours you are available to volunteer. Although the Clinic’s current schedule is Saturdays, 8:30 am to 12:30 pm, certain tasks require help at other times.

Please indicate all available days/times:
How often would you like to volunteer?

If Other
Length of commitment duration:

If Other
Can you provide healthcare in language(s) other than English? If yes, please identify which one(s):

If Other
How did you learn about the Free Access Health Clinic?
Have you ever been convicted of a crime?

If Yes, please explain
Background Check Authorization: I authorize Free Access Health Clinic to conduct a background check as part of the application process. I understand that the information gathered will be used for evaluation purposes only.

Contact Information

Employer Name
Work Email Address
Work Phone
Work Mailing Address
In case of emergency, notify:

Please list the name, email and phone number of three personal/professional references (please, do not list relatives):


FTCA Free Clinics Insurance Information

The clinic’s malpractice insurance is provided by the Federal Government through the Federal Tort Claims Act; Free Clinics Insurance Program. In order for you to volunteer with the clinic, you must be credentialed and then deemed (approved) by the FTCA government program. This can take approximately 8 weeks. The following information is needed to complete this process:

Date of Birth
School of Graduation
Year of Graduation
School Address
Highest level of education completed?
Are you currently in school?

If yes, graduating in:

Roles and Specialty

Administrative Positions

If Other
Specialist Technologist and Other Technical Service Providers:

Board or Executive:

Individual Type

Individual Type

Service Type

Individual Status

Your name below indicates your permission to allow Free Access Health Clinic staff to contact the references listed above and that the information provided in this application is correct.

The form has been submitted successfully!
There has been some error while submitting the form. Please verify all form fields again.

Opportunities for volunteers are provided without regard to religion, creed, race, national origin, age, sexual orientation, or gender.