Healthcare Professionals Volunteer Application

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


Former Name
Professional Designation

If Other
Address in Vermont
Phone (Home)
Phone (Work)
Phone (Cell)
Fax (If Any)
Are you currently in school?

If Yes, expected year of graduation?
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/Time:
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

Contact Information

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

Home Phone
Cell Phone
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

Roles and Specialty

Specialty Physicians (Check all that apply):

If Other
Specialty-Behavioral Health and Social Service Providers (Check all that apply):

If Other
Specialty-Dietary and Nutritional Service Providers:

Specialist-Nursing Service Providers:

Pharmacy Service Provider:

Specialist-Physician Assistant and Advanced Practice Nursing Providers:

Specialist-Podiatric Medicine and Service Providers:

Estimate how many hours on average per month you will you work as a volunteer health professional?

Individual Type

Individual Type

Service Type

Individual Status

Licensure and/or Certification

State of Licensure:
Expiration Date:
Is Licensure Active (Select N/A if you are not licensed or certified)?

DEA # (if applicable):
NPI # (if applicable):
Any Additional Licenses?

If Yes, State and Occupation:
CPR Certified:

Date of Last Credentialing:
Date of Last Privileging:

Medical Malpractice and Disciplinary Actions History

Do you have any history of state Board disciplinary actions and/or state or federal court (including any FTCA) malpractice claims within 5 years of prior to the submission of this FTCA volunteer health professional deeming application? Include both pending and resolved administrative and civil claims.

Clinical license in any jurisdiction:

Other professional license:

DEA certificate:

Privileges on any hospital medical staff:

Membership on any hospital medical staff:

Board Certification:

Any other professional sanction:

Have you ever been subject to any disciplinary action in any health care organization or is any action currently pending?

Are you under any special monitoring requirements?

Have you ever resigned or taken a leave of absence in order to avoid possible revocation, suspension, or reduction of privileges at any hospital or clinic?

Have you had any malpractice cases filed against you?


If yes, attach a list of claims or actions (include probationary actions.) For each claim, suit or action include the following details and explanation:

• Area of practice/specialty
• Date of occurrence
• Summary of allegations
• Status or outcome of claim or action

Enter any comments and an attachment with an explanation of each medical malpractice or disciplinary action.
Your signature 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.

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