Non Medical Volunteer Application

Address

Employment
Occupation
Currently Employed?
Volunteer Experience
Community Affiliations (Clubs, Service Organizations, Etc.)
License or Certification(s) (LMSW, etc.)
Previous Volunteer Experience
Languages Spoken
References
Reference Name
Please list a reference not related to you
Years Known
Reference Contact Information
Have you ever been convicted of or plead guilty to any crime(s) other than minor traffic violations?
Yes
No
Please Explain

Volunteer Information
How Did You Hear About FernCare?
Days/Times You Are Available To Volunteer?
Which of the following areas would you be willing to volunteer in? (Please check all that apply)
* FernCare uses Athena EMR. Orientation is at the clinic after you have been accepted as a volunteer
Non Medical Staff
Community ResourcesStatistician *
Receptionist/Appointment Desk *Social Worker/Counselor
Health Insurance AssistOffice and other Administrative Assistants
Information TechnologyOthers
Driver’s License/Government ID
Filename
Size
Process
Status
Add Files
Only pdf, jpg, jpeg, png files are accepted (Max 5MB)
Date of Last Tetanus Shot
Month - Day - Year
As a condition of volunteering, I give permission to the FernCare Free Clinic to conduct a Michigan State Police background check on me.

I hereby release and agree to hold harmless from liability the FernCare Free Clinic, the employees and volunteers hereof or any other person that may provide such information.

I also understand that the FernCare Free Clinic is not obligated to appoint me to a volunteer position.

If appointed, I understand that I am subject to suspension and removal for violation of FernCare Clinic policies and procedures.
Full Legal Signature
Datetime
Month - Day - Year
Captcha

Want to volunteer where you
can make a difference?