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Volunteer Applicaton
Personal Information
Name
*
First Name
Last Name
Date of Birth
*
(mm/dd/yyyy)
Phone
*
Email
*
Verify Email
*
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
If you are under the age of 18 you will be asked to provide a signed note of permission from your parent or legal guardian.
*
I understand that if I am under the age of 18 that I will be required to bring a signed note from my parent or guardian prior to my first day of volunteering.
I am over the age of 18 and this does not apply to me.
Do you have your current immunization record?
*
Yes, and I understand that I will have to present before my first day of volunteering.
No, but I understand that to be eligible to volunteer that I must provide proof of current immunizations.
Emergency Contact Information
Name
*
First Name
Last Name
Phone
*
Relationship to You
*
Education, Experience and Skills
Are you currently employed
*
select one
Yes
No
Current Employer's Name
*
Phone
*
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Do you speak any languages other than English?
*
select one
Yes
No
What languages do you speak/read/write? Please list your fluency. Each new language should be on its own line.
*
List any skills or training that supports your volunteer interests.
List any other volunteer experiences you have had.
Are you willing to provide either volunteer or professional references?
*
select one
Yes
No
Please indicate their name, email address, telephone, and relationship to you, with each new reference on their own line.
*
About the PWAFC
Are you willing to make a one year commitment to be a volunteer at the PWAFC?
*
select one
Yes
No
Maybe
If you answered 'Maybe' to the question above please explain here.
*
Please indicate what you are seeking to volunteer as.
*
Administrative Volunteer
Medical Volunteer (Must have a medical license)
Provider (Must be licensed in the state of VA)
Please indicate which professional licenses you currently hold
*
CMA
CNA
CNS
LPN
RN
Pharm Tech
PharmD
Other
Not Applicable
Your license number
*
Your license expiration date
*
(mm/dd/yyyy)
Please indicate which professional licenses you hold.
*
DDS
DO
MD
NP
PA
Other
Not Applicable
Your License Number
*
Your License Expiration
*
(mm/dd/yyyy)
Your Specialty
*
Briefly state why you wish to volunteer at the clinic.
*
How did you learn about the clinic?
*
Volunteering Schedule
How many days a week would you like to volunteer?
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Availability to volunteer. Please check all that apply.
*
Monday
Tuesday
Wednesday
Thursday
Remote Events
Times you are available on Mondays
*
Morning
Afternoon
Not Available Today
Frequency
*
select one
Daily
Weekly
Bi-Weekly
Monthly
Times you are available on Tuesdays
*
Afternoon
Evening
Not Available Today
Frequency
*
select one
Daily
Weekly
Bi-Weekly
Monthly
Times you are available on Wednesdays
*
Morning
Afternoon
Not Available Today
Frequency
*
select one
Daily
Weekly
Bi-Weekly
Monthly
Times you are available on Thursdays
*
Morning
Afternoon
Not Available Today
Frequency
*
select one
Daily
Weekly
Bi-Weekly
Monthly
To attend remote events are you willing to take time off during the work week and travel to different organizations on your own to represent the clinic and its programs?
*
select one
Yes
No
It Depends
Not Applicable
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.
Are you applying to be a volunteer to complete a requirement?
*
select one
Yes
No
If you answered 'Yes', for which organization?
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Organizational Contact
First Name
Last Name
Organizational Phone
Number of Hours Required
*
Expected Date of Completion
*
(mm/dd/yyyy)
Statements and Authorizations
Confidentiality Statement
*
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.
select one
Yes
No
Background Check Authorization
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.
Yes, I agree to a background check.
No, I do not agree and understand that this precludes me from being a volunteer at the PWAFC.
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.
I wish to receive a copy of any Background Check Report on me that is requested
Not Applicable
The average application review time varies depending on our current needs . Please submit only one application. We will get back to you as soon as possible. If you have questions you can send an email volunteer@pwafc.org.
We are currently in need of volunteers to translate and volunteers with open or flexible availability.
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First Name
Last Name
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