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Volunteer Sign Up
Personal Information
Name
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First Name
Last Name
Phone
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Email
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Verify Email
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Address
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Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Are you vaccinated against COVID-19?
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Yes
No
If you indicated "No" above, please elaborate
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If you indicated "No" above, please elaborate
Application Information
Please indicate your availability
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Monday from 8:30am-noon
Monday from 6pm - 9pm
Tuesday from 9am - noon
Tuesday from 12:15pm - 3pm
Wednesday from 9am-noon
Thursday from 9am - noon
Thursday from 6pm - 9pm
Which volunteer roles are you interested in? Please check all that apply.
MDs, PA-Cs, ARNPs
Staffing Physician
Examiner (M3, M4, MSTP, PA-C, ARNP)
Specialty Care Provider
Dentists and Dental Assistants
Pharmacy Technician
Phlebotomist/Lab Technician
Interpreter
Reception
Clinic Assistant
Other Volunteer Role?:
Please list your language proficiency/ies beyond English.
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Have you ever been arrested? If yes, please explain.
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If you are volunteering to fulfill a community service requirement, please state your offense and the number of hours you must complete.
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Did someone refer you to volunteer at the FMC?
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Anything else you'd like us to know?
Terms and Conditions
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I confirm that the facts presented in my application to become a clinic volunteer are true and complete. I understand that if my application is accepted, false statements on this application shall be considered sufficient cause for my termination from the program. I understand that this application does not obligate me to become a Free Medical Clinic volunteer, nor does it obligate Free Medical Clinic to accept me as a volunteer. I know of no reasons why I cannot be accepted as a volunteer at the Free Medical Clinic and I hereby grant permission for the Iowa City Free Medical clinic to investigate my background as they see fit.
Confirm
Signed (Type your full name)
*