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Volunteer Applicaton
Personal Information
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First Name
Last Name
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(mm/dd/yyyy)
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
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Emergency Contact Information
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First Name
Last Name
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Experience and Skills
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
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About the PWAFC
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(mm/dd/yyyy)
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(mm/dd/yyyy)
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Volunteering Schedule
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Seeking Credit for Hours
Please note that we do not provide any proctorship opportunities at the provider level. Our proctorship opportunities for RN and LPN students must have an organizational agreement between their school and the PWAFC.
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First Name
Last Name

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(mm/dd/yyyy)
Statements and Authorizations
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I understand that all professional standards regarding medical confidentiality, such as HIPAA, apply at the Prince William Area Free Clinic. This includes but is not limited to, prohibition against copying medical records, removing medical records from the clinic, and/or divulging information from the medical records to anyone else. All requests for such matter should be referred to the clinic staff.
The information contained in this application is correct to the best of my knowledge. I hereby authorize Prince William Area Free Clinic and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/ investigative consumer report may include, but is not limited to the following areas: verification of social security number; credit reports, current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records. I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, to or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources. Prince William Area Free Clinic and its designated agents and representatives shall maintain all information received from this authorization in a confidential manner in order to protect the applicant's personal information, including, but not limited to, addresses, social security numbers, and dates of birth.
Notice to California, Minnesota and Oklahoma Residents: Please check the box below if you wish to receive a copy of a consumer report that is requested.
The average application review time is one week. If you have not heard from us after one week please follow up by emailing volunteer@pwafc.org.