Burnstein CHC Volunteer Form
First name
*
Last Name
*
Address
City
State
Zip
Phone
*
Date of Birth
MM
01
02
03
04
05
06
07
08
09
10
11
12
DD
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
1910
1911
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Drivers License#
Occupation
If you have a medical background, in what field
Emergency Contact
Contact Phone
email address
Community Affiliations
Previous Volunteer Experience
Special Certifications
Reference not related to you
Phone # of Reference
Have you ever been convicted or plead guilty to any crime(s), other than minor traffic violations
No
Yes
If yes, please specify
Times and Days you are available to volunteer
Medical: Which of the following areas would you be willing to volunteer in?
Doctor
RN
Dental
PAP
Pharmacist
Other
NonMedical: Which of the following areas would you be willing to volunteer in?
Reception
Database/Computers
Fundraising
Other
Acknowledgment of Conditions
*
Acknowledged
As a condition of volunteering, I give permission for the Gary Burnstein Community Health Clinic to conduct a background check on me. I hereby release and agree to hold harmless from liability the Gary Burnstein Community Health Clinic, the employees and volunteers thereof, or any other person that may provide such information. I also understand that the Gary Burnstein Community Health Clinic is not obligated to appoint me to a volunteer position. If appointed, I understand that I am subject to suspension and removal for violation of Gary Burnstein Community Health Clinic policies and procedures.
Security Code:
*
Reload Image
::
PHP FormMail Generator
::