Good Samaritan Free Clinic

Date:
E-mail Address: *
Referred by:
Name:
Address:
City:
State:
Zip:
Home phone:
Work phone:
Cell phone:
Are you available Monday Evenings, 5-9 pm, arriving at approx. 4:45?	YES NO
Are you available Thursday mornings, 8am - 12 pm, arriving at approx. 7:45?	YES NO
During which week(s) of the month do you wish to volunteer?	1st 2nd 3rd 4th Flexible
List 2 personal references including name and contact number:
Do you speak any other languages?
Do you have skills that would assist the running of the clinic?
Have you ever been a patient at the clinic?	YES NO
By checking the box I indicate my understanding that as a volunteer I represent the Good Samaritan Free Clinic and agree to act in a manner consistent with the safety, confidentiality and patient treatment practices as outlined in the job description and policiy and procedures of the clinic.


* Required

Click here to open a printable version of the volunteer form.