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Order Number

PERSONAL INFORMATION

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

How did you hear about us? Select an option below *

Friend Volunteer School Internet Media Other

If Other Please Specify

Are you a Florida Licensed Medical Practitioner? *

Yes No

If yes, please specify your specialty and years of experience in your field of expertise.

Will you be receiving certification/academic or internship credit? *

Yes No

If yes, please indicate the program/school/degree and total of hours needed

Why are you seeking volunteer opportunities? *

Are you able to provide a minimum of 3 to 6 months service hours? *

Yes No

SKILLS AND INTERESTS

What type of volunteer work are you interested in? Please check all that apply.

Clerical

Answer Phones Filing Data Entry

Patient Care Services

Vitals Translation Scribing Medical Assistant Responsibilities

PC Skills

Microsoft Office Medical Software

List Medical Software

Special Skills/Training?

Customer Service

Office Equipment

Data Entry Clerical Skills

Outreach Events

Other Skills

What is your availability? *

Other than English, do you speak other languages? If yes please indicate language and proficiency

Language

Able to translate

Yes No

Able to translate

Yes No

EXPERIENCE

Do you have any previous volunteer experience? *

Yes No

If yes, please explain when, where and duties performed:

AGREEMENT AND SIGNATURE

By submitting this form, you affirm that the facts set forth in it are true and complete. You also understand that if accepted as a volunteer, any false statement, omissions or other misrepresentations made by you on this form may result in immediate dismissal.

Signature: *

Date: *

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