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Application for Volunteer, Internship, or Clinical Rotation

Are you interested in a Volunteer, Intern, or Clinical Rotation position?*
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First Name*
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Last Name*
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Street Address *
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City*
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State*
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Zip*
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Phone Number*
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Email*
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Emergency Contact*
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Parent/Guardian, Spouse, etc.

Emergency Contact Phone Number*
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Education Background*

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Is this volunteer service required by school?*
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Are you a medical student?
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Which school are you a student at?
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If Other, which school or program are you affiliated with?
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If you are a licensed professional, what is the current status of your license?
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Unfortunately, Neighborhood Healthcare does not accept volunteers with a ‘restricted’ license. Thank you.
Do you have language skills other than English?
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If yes, can you speak fluently?
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Which languages can you read

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If other, what language(s) can you read?
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Which languages can you speak?

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If other, what language(s) can you speak?
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Which languages can you write?

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If other, what language(s) can you write?
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Name of person we should contact at school:
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Phone Number for school contact:
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Have you ever worked at Neighborhood Healthcare?*
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If Yes, in which department did you work?
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Have you ever volunteered at Neighborhood Healthcare?*
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If Yes, in which department did you volunteer?
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Are you currently, or have you ever been, a patient at Neighborhood Healthcare?*
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If yes, at which site were you a patient?

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Which Neighborhood Healthcare location(s) would you like to volunteer at?*

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What date are you available to start volunteering?*
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Availability
Mon

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Tues

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Wed

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Thurs

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Fri

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Sat

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Which department or program(s) would you like to volunteer with?*

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Please let us know what other department or program you would like to volunteer with.
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What would you like to gain from this experience?*
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How did you hear about Neighborhood Healthcare?*

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How did you hear about Neighborhood Healthcare?
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Did someone refer you for this volunteer/intern position?*
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If yes, what is their name? Please include their first and last name.
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Additional comments or notes
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