Volunteer Application

First Name *

Middle

Last Name *

Preferred for name badge

Address *

Address 2 (Apt,Suite, Bldg) Optional

City *

State *

Zip Code *

Email *

Phone (Home)

Phone (Work)

Phone (Cell)

In Case of Emergency Please Notify *

Relationship to Volunteer

Phone *

Professional Healthcare Provider License in NC?

Type

License #

Other

Please list two references *

Phone *

Email *

Relationship to Volunteer *

Please list two references (copy) *

Phone *

Email (copy) *

Relationship to Volunteer *

VOLUNTEER APPLICATION AGREEMENT

1. I certify that my answers on this application are true. 2. I authorize New Hope Clinic to verify the information submitted in this application and to contact the references provided. 3. If accepted as a volunteer at New Hope Clinic, I agree to abide by the rules and regulations of New Hope Clinic, Inc. 4. My services are donated without contemplation of compensation or future employment. 5. I shall not solicit any business for attorneys or insurance companies “for compensation”, both on or off Clinic property, or act as a runner for an attorney in the solicitation business. I shall report all known occurrences of solicitation for attorneys. 6. I shall not sell or attempt to sell goods or services, request contributions, or solicit persons to sign or distribute political petitions on Clinic premises. 7. I shall attempt to resolve any problems related to my volunteer activities with the New Hope Clinic Executive Director. 8. I understand that the Clinic reserves the right to terminate my volunteer status as a result of (a) failure to comply with Clinic policies, rules and regulations; (b) absences without prior notification; (c) unsatisfactory attitude, work, or appearance; or (d) any other circumstances which, in the judgment of the Executive Director, Medical Director, Dental Director, or Pharmacy Director, would make my continued service as a volunteer contrary to the best interests of the Clinic.

I have read each of the above conditions and I agree to be bound by them *

By checking this box I am agreeing to the terms of the volunteer application agreement.

Security Verification *