La Clinica del Pueblo - Volunteer Form

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Volunteer Form

Volunteer at La Clínica!

You must provide a copy of a tuberculin skin test within the past year or proof of a positive TB test and a negative chest x-ray by your starting volunteer day at La Clínica. Also please know that we have had individuals shadow physicians, however, there is no guarantee.

If you have any questions or want more information, please do not hesitate to contact us. Thank you for your interest in volunteering with La Clinica del Pueblo, Inc.

Personal Information

*First Name		*Last Name
*App Date		DOB
Address

City		State
Zip		Email
Phone#1:		Phone#2:
Emergency Contact
Emergency Phone

Employment/Professional Experience

Occupation/Title:		From/To:
Current Employer:		Phone:
Please list any other pertinent professional experience you have along with contact information

Education & Special Skills

High School	Year	Degree
College	Year	Degree
Graduate	Year	Degree
Other Training	Year	Degree
Please tell us about any other areas of study, trainings, classes, and/or certificates and degrees received:

Please list any other language(s) you speak:

Volunteer Experience

Agency 1 Location

From/To

Briefly describe the area/type of work:

Agency 2 Location

From/To

Briefly describe the area/type of work:

Agency 3 Location

From/To

Briefly describe the area/type of work:

Availability

*If asked to volunteer with us how soon can you begin?

Are you able or willing to make a time commitment?

Yes No

Hours Available			Specifications (i.e. only evenings, available on weekends, etc.)
Mondays:	(from)	(to)
Tuesdays:	(from)	(to)
Wednesdays:	(from)	(to)
Thursdays:	(from)	(to)
Fridays:	(from)	(to)
Saturdays:	(from)	(to)

Please put a check by the program(s) or divisions at La Clinica del Pueblo that interest you the most. We will do our best to match YOUR interests; however, this is not always possible.

Administration Community Health/Education Data Entry Health Fairs HIV/AIDS Program Mental Health Pediatrics Reproductive Health Social Services

References

Name:		Relation:
Phone#:
Name:		Relation:
Phone#:

Resume

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Serving the community since 1983
© La Clinica del Pueblo 2008

2831 15th Street, NW - Washington, DC 20009-4607 (202)462-4788