Non-Medical Volunteer Form - Barrier Islands Free Medical Clinic

First Name *

Last Name *

Address *

Address

City

State/Province

Zip/Postal

Home Phone

Cell Phone

Office Phone

Email Address

Preferred Method of Contact

Availability

Hours

9:00 am - 1:00 pm (M, T, W, Th, F)

1:00 pm - 4:00 pm (M, T, W, Th, F)

Other

During the time I am in SC

Months/Days:Months/Days:

On average, how many hours per week can you typically volunteer? (select best answer from dropdown)

Previous Volunteer Experience

Please Provide a Copy of Your CV or resume, if available (not a requirement).

Resume or Supporting Document

Maximum upload size: 10.49MB

If you would like to submit a resume or supporting document, please upload here.

Can you commit to attending at least one outreach/health fair event per year? Typically these will occur on a Sat/Sun

Have You Ever Been Convicted of a Felony?

The Clinic requires all volunteers to undergo appropriate background checks. For non-medical volunteers, we check SLED. Please Provide A Copy of Your Driver’s License.

Person to Notify in Case of Emergency

Name

Address

City

State/Province

Zip/Postal

Home Phone

Work Phone

Cell Phone

Email Address

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 non-medical duties 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.

Where did you learn about Barrier Islands Free Medical Clinic?

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