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Non-Medical Volunteer Form
Non-Medical Volunteer Form
Non-Medical Volunteer Form
First Name
*
Last Name
*
Address
*
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Home Phone
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Email Address
Preferred Method of Contact
Home Phone
Cell Phone
Office Phone
Email
Availability
Days
Monday
Tuesday
Wednesday
Thursday
Friday
Hours
6:00 pm - 9:00 pm (Monday only)
9:00 am - 1:00 pm (T, W, Th, F)
1:00 pm - 4:00 pm (W, Th, F)
Other
During the time I am in SC
Months/Days:
Previous Volunteer Experience
Please Provide a Copy of Your CV or resume, if available (not a requirement).
Resume or Supporting Document
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If you would like to submit a resume or supporting document, please upload here.
Interests
Interpreting
Front Desk
Appointment Reminder Calls
Data Entry
Clerical
Appointment Scheduling
Case Management
Pickups & Deliveries
Special Projects
Health Fairs
Wine Festival Event
Golf Event
Other Event
Sponsorship Soliciation
We need a variety of non - medical volunteers. Please check all duties that you would be interested in providing for BIFMC.
Have You Ever Been Convicted of a Felony?
Yes
No
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
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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?
Internet/Website
Social Media
Television
Radio
Friend or Volunteer
Newspaper/Magazine (please list)
Other
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