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
HOME
OUR CLINIC
About Us
Board of Directors
>
Board Access
Patient Testimonies
Contributors
Videos
DONATE
Give Now
Donations
PATIENTS
New Patients
Services
Veterans Dental Program
Mini-Mission of Mercy
Eligibility Criteria
Online Application
Upload Documents
Online Payment
Privacy Practices
VOLUNTEER
Volunteer Opportunities
Volunteer Application
FUNDRAISERS
Wine Tasting
Taste of Chesapeake
Run For the Health of It
NEWS & RESOURCES
Annual Report
Newsletter Sign Up
Newsletter Archive
Facebook
CONTACT US
Contact Us
Hours of Operation
Location