Volunteer Application

Chesapeake Care Clinic

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V O L U N T E E R A P P L I C A T I O N

JOIN OUR TEAM TODAY!

To become a Chesapeake Care Clinic volunteer, please fill out the application below.
We will contact you to schedule a time for orientation!

VOLUNTEER APPLICATION FORM

PERSONAL INFORMATION

* Indicates required field

Last Name *

First Name *

Middle Name *

Date of Birth *

Street Address *

Apt/Lot # *

City *

State *

Zip *

Home Phone # *

Cell Phone # *

Consent to Text *

Yes No

Place of Employment *

Email *

Work Phone # *

Best Phone # and Time to Contact You *

How did you learn about Chesapeake Care Clinic? *

Are you volunteering to complete a requirement? *

Yes No

If yes, which organization: *

Contact Person *

Hours Required *

Phone Number *

Required Date of Completion *

EMERGENCY CONTACT

Name *

Phone # *

SCHEDULE INFORMATION

How often would you be available? *

Select your preferred volunteer times:

AM *

Tuesday Wednesday Thursday Friday

Afternoon *

Tuesday Wednesday Thursday Friday

PM *

Tuesday Wednesday Thursday

LICENSED VOLUNTEER

Are you active military? *

Yes No

Do you file a Virginia State Tax return? *

Yes No

Professional License: *

DDS DO LPN MD NP PA RDH RN RPH

DEA #: *

Professional License #: *

Initial License Date: *

Expiration Date: *

State License: *

NPI #: *

If you have a professional license, you are protected from liability if you are practicing within the scope of your license without compensation at a free clinic. You can only be sued for willful negligence. In order to establish the protection, we must have a copy of your current license on file. Be advised that Universal Precautions must be followed for all patient contact. By typing my name, I understand the above statement. *

Submit

CHESAPEAKE CARE CLINIC
2145 S. Military Highway Chesapeake, Virginia 23320
(757) 545-5700

Website by Darin Kennedy
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HOME
OUR CLINIC
DONATE
- Give Now
- Donations
PATIENTS
VOLUNTEER
- Volunteer Opportunities
- Volunteer Application
FUNDRAISERS
NEWS & RESOURCES
CONTACT US