*(denotes required field)

Name: *

E-Mail Address: *

Referred By

Address *

Home Phone

Cell Phone

Work Phone

Are you available Monday Evenings, 5-9 PM, arriving at approx. 4:45? *

Are you available Thursday mornings, 8am - 12 pm, arriving at approx. 7:45? *

During which week(s) of the month do you wish to volunteer? *

List 2 personal references including name and contact number *

Do you speak any other languages?

Do you have skills that would assist the running of the clinic?

Have you ever been a patient at the clinic? *

Typing your name as an electronic signature indicates your understanding that as a volunteer you represent the Good Samaritan Free Clinic and agree to act in a manner consistent with the safety, confidentiality and patient treatment practices as outlined in the policies of the clinic. *