Community Volunteers

Fill out the online volunteer application below
to help PFC/VCN. If you prefer to print and mail
or fax your application, download the PDF.

Contact Information

Full Name: Phone Number: Address:

City:

State:

Zip Code:

Email Address: Emergency Contact Name: Emergency Contact Phone Number:

Availibility

What hours are you available on Monday evening for volunteer assignments?

3:30 PM
4:00 PM

5:00 PM
6:00 PM

Interests

Areas you are interested in volunteering:

Front Desk
Medical Records
Patient Registration
Patient Concierge
X-ray Technician
Patient Escort (Hall)
Take Vitals/Weights
Interpreter (Language)

Room Fillers
Vision Screening
Nurse Practitioner
Pharmacist
RN/LPN/MA
Food Bank
Pre-Greeting

Special Skills or Qualifications

Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities.

Previous Volunteer Experience

Personal References

Reference #1 Full Name: Phone Number: Position:

Reference #2 Full Name: Phone Number: Position:

By agreeing to these terms and conditions, I affirm that the facts set forth in it are true and complete and I give permission to the Physicians Free Clinic / Volunteer Care Network to check my references. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.

Accept
Decline

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PFC/VCN

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