Trained Medical Interpreter and Translator 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


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
What is your native language?
Into what language are you able to interpret/translate?

If Other
Please describe your experience learning and using your non-native language(s):
Please describe your experience interacting with individuals and groups from cultural backgrounds other than your own:
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:

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

Please list the name, email and phone number of two individuals who will submit language evaluations on your behalf. We prefer that external language evaluations come from language professionals with current knowledge of your language ability. This is often a language instructor, teacher or professor. If you do not have someone to assess you, we can arrange this through our network of evaluators.


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:

Individual Type

Individual Type

Role or Specialty

If Other
Service Type

Individual Status

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.