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Volunteer Application

Choose one: Mr Mrs Miss Ms Dr
First Name: Last Name:

Home Street Address:
City: State: Zipcode:

Work Street Address:
City: State: Zipcode:


Home Phone: Work Phone:
Cell Phone: Fax:

Email Address:

Birth Date: Occupation:

In case of emergency, contact:
Name: Phone:

Please check all that apply:

Availability: Daytime Thursday Evening Weekly Monthly Quarterly

Skills: Computer Clerical Fundraising CPR First Aid
Other Skills:
Languages Spoken:

Please state your reasons for wishing to volunteer at the Free Clinic of Culpeper:


I am interested in the following volunteer opportunities for which I believe I am qualified:
Appointment Scheduler Eligibility Screener Medical Screener Nurse
Office Worker Physician Pharmacist Pharmacy Assistant Receptionist
Other Opportunities:

If you are a licensed health care professional, please provide the following information:
Specialty: VA Board of:
License No.: Expiration Date:
DEA No.:

We recommend that all our volunteers have the following immunizations. Please check those that you have received and enter the date:
Hepatitis B vaccine. Date series completed:
Tetanus toxoid. Booster date:
TB test. Date:

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