Non-Medical Volunteer Form

First Name *

Last Name *

Address *

City

State/Province

Zip/Postal

Home Phone

Cell Phone

Office Phone

Email Address

Preferred Method of Contact

Previous Volunteer Experience

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

Resume or Supporting Document

Drop a file here or click to upload Choose File

Maximum upload size: 16.78MB

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

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?

Internet/Website

Social Media

Television

Radio

Friend or Volunteer

Newspaper/Magazine (please list)

Other

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Non-Medical Volunteer Form

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Person to Notify in Case of Emergency