Olde Towne Medical & Dental Center · Volunteer Interest Form

Contact Information

Name *

First Name

Last Name

Email *

Verify Email *

Phone *

Volunteering Eligibility

Are you over 18? *

Yes

No, Thank you for your interest, but volunteers must be 18 or older.

Are you a patient of Olde Towne Medical & Dental Center? *

Yes. Sorry, but due to conflict of interest we do not allow patients to volunteer in the clinic. The exception is Events & Outreach.

No

If you are a licensed medical or dental professional's only, would you be willing to complete a background check? *

Yes

No

N/A

Interests and Qualifications

Do you speak another language, if so please write below.

List your qualifications

Do you have a professional background or work experience in any specific areas? This would include past or present professional licenses or certifications. Check all that apply.

Accounting or Billing

Behavioral Health

Dental

Medical

Other

Elaborate on experience listed above, explain other, and/or list relevant licensure/certifications.

Is there any other information you would like to share?

Availability and Documentation

Why are you interested in volunteering?

want to give back to my local community.

am a college student and planning for my future.

am retired and want to help out.

Required Paperwork

Open, read, and acknowledge understanding of the following policies.

Cell Phone Use Policy
Confidentiality Agreement
Internet Use Policy
HIPAA Training- please complete training through this website and send the Certificate of Completion to Susan Dunn

I have read, understand, and acknowledge the policies outlined above.

I have read, understand, and acknowledge OTMDC's Cell Phone Use Policy, Confidentiality Agreement, Internet Use Policy, and completed the HIPAA Training module (please send completed certificate to susan.dunn@jamescitycountyva.gov).

Thank you for your interest, we will review your information and contact you soon. Currently we are looking more for Spanish translators, clerical help, as well as events and outreach.