Non-Medical Volunteer Form

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First Name *

Last Name *

Address *

Address

City

State/Province

Zip/Postal

Home Phone

Cell Phone

Office Phone

Email Address

Preferred Method of Contact

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

Drop a file here or click to upload Choose File

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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Person to Notify in Case of Emergency