Volunteer form - Volunteers in Medicine Clinic

Name

First

Last

Email

Phone

Address

Address Line 1

City

State

Zip Code

Age range

Your desired volunteer activity

Community service and work history

Please attach a resume or tell us about your community service and work history below.

Attach: Community service and work history

Click or drag a file to this area to upload.

Preferred number of four-hour shifts

Availability

Do you have physical limits?

If yes, please describe your physical limits below

work to Your

Your computer skills

Your computer experience

Please list any programs you have experience with (eg. Microsoft Excel, Microsoft Word, Drupal)

Your schools, degrees and/or professional certificates

Please list your schools, degrees and professional certificates.

Reference #1 Name

Please list a person we can use as a personal or professional reference.

Reference #1 Contact Phone

Relationship to Reference #1

Please describe your relationship with your reference.

Reference #2 Name

Please list a person we can use as a personal or professional reference.

Reference #2 Contact Phone

Relationship to Reference #2

Please describe your relationship with your reference.

Referred to VIM by