Volunteer Request Form

PERSONAL INFORMATION

First Name:*

Last Name:*

Address:*

City*

State:*

Zip Code:*

Phone Number:*

E-Mail Address:*

How did you hear about us:*

Please specify:*

Are you Florida Licensed Medical Practitioner?*

Yes

Please specify your specialty and years of experience in your field of expertise.*

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

Yes

Please indicate the program/school/degree and total of hours needed.*

Why are you seeking volunteer opportunities? Please share your motivation for volunteering with us.

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

Yes

SKILLS AND INTERESTS

What type of volunteer work are you interested in?*

Clerical

Outreach Events

Patient Care Services

Please specify clerical work you are interested in:*

Answer phones

Filing

Data Entry

Please specify patient care services work you are interested in:*

Vitals

Translation

Scribing

Medical Assistant Responsibilities

List any of your special skills/training?*

Please specify your PC skills:*

Microsoft Office

Medical Software

Which medical software are you familiar with?*

Please provide details of your other skills:*

What is your availability?*

Other than English, do you speak other languages?*

Yes

Pease indicate language and proficiency:*

Able to translate:*

Yes

Do you speak any other language?*

Yes

Pease indicate language and proficiency:*

Able to translate:*

Yes

EXPERIENCE

Do you have any previous volunteer experience?*

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 statements, omissions or other misrepresentations made by you on this form may result in immediate dismissal.

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Date of Signature

OUR POLICY

It is clinic policy to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.

As a volunteer-based 501c3, we rely on the kindness of our licensed and non-licensed volunteers to provide quality healthcare services or support to the uninsured low-income residents of Broward County. It’s our goal to best match your skill set(s) to our current needs. Should there be a possible match, we will contact you to further discuss how we may work together and if licensed, invite you to complete a licensed volunteer application. Thank you for completing this form and for your interest in volunteering with the Light of the World Clinic.