Good Samaritan Free Clinic
             Helping to Bridge the Gap in Healthcare
         Professional Medical Volunteer Information Sheet

Please Print:

Date: _________________   Referred by: ______________________________

Name: _______________________________________________________________

Street Address: _____________________________________________________

City: ___________________   State: __________   Zip: ________________

Home Phone: _________________          Work Phone: __________________

Cell Phone: ___________________        E-mail: ______________________

1.  Which day(s) are you available?      ___ Monday Night; 5pm-9pm
                                         ___ Thursday Morning; 8am-12pm

2.  During which week(s) of the month do you wish to volunteer?   
      ____ 1st    ____ 2nd    ____3rd    ____4th     ____ Flexible

3.  Name two personal references:
      1._______________________         2.______________________
      
      # _______________________         # ______________________

4.  Do you speak any other languages?  ______________________________

5.  Last two places of employment:
      
      1.  __________________________________________________
      
      2.  __________________________________________________ 

6.  License # _______________________________  Exp. Date: _______________
    (We need a copy of your license on file; please attach or supply ASAP)


I _____________________________ understand as a volunteer, I represent the 
Good Samaritan Free Clinic, and I agree to act in a manner consistent with 
the safety, confidentiality and patient treatment practices as outlined in 
the job description and policy and procedures of the clinic.