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


Prefix



Name
Address in Vermont
Phone (Home)
Phone (Work)
Phone (Cell)
Email
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:

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

1)
2)
3)

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?
Degree
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.

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