Medical Volunteer Application

Medical Volunteer Application
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State/Province
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Availability

What days and times are you available to volunteer? If you live here part-time please complete the "Other" section
Please summarize your previous volunteer experience.
Drop a file here or click to upload Choose File
Maximum upload size: 2.1MB
If you would like to submit a CV or supporting document, please upload here.

Please Provide the Following:

The Clinic requires all volunteers to undergo appropriate background checks. For medical volunteers, we check SLED, the Medical Licensing Board and the National Practitioner Data Bank.

References

Please provide contact information for two professional references that we may contact.
Name
Name

Person to Notify in Case of Emergency

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State/Province
Zip/Postal
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By submitting this application, I understand that as a volunteer, I will give of my time and talents to the mission of the Barrier Islands Free Medical Clinic, Inc. to provide medical care for the uninsured population of Johns, Wadmalaw and James Islands, without compensation. I agree to undergo all required background checks and to abide by current HIPPA legislation.
City
State/Province
Zip/Postal
Country

Person to Notify in Case of Emergency

City
State/Province
Zip/Postal
Country
Sending