2018 General Volunteer Application


Thank you for your interest in volunteering with the Coachella Valley Volunteers In Medicine clinic! Our mission is to provide no-charge, primary health care services to medically underserved people residing in the Coachella Valley. We do this predominately through the provision of primary medical and dental care, though certain medical specialty services are also provided.

We rely on the time and talents of volunteers to complete a variety of tasks to keep the clinic operating efficiently. We ask those who accept a volunteer position with CVVIM to commit to a minimum 5-hour shift, 2 shifts per month for an initial 3-month period.

Before receiving a volunteer assignment, each candidate must complete:

  • A personal interview
  • One (1) hour of Orientation & Training
  • Attend ongoing Volunteer Meetings as scheduled
  • Be at least 18 years old
  • Authorize a Background Check. We ask for a $10 donation to offset expense.
  • Sign a Service Commitment form (minimum 5 hour shifts, 2 shifts per month)
  • Complete HIPPA training & sign the Confidentality Agreement
  • Maintain proper Dress Code (scrub top; choice of bottoms, no ripped or low-rise jeans)
  • CVVIM Logo Scrub Top available for $20 purchase.
Please consider these requirements carefully before deciding to become a volunteer.

  INTEREST
  APPLICATION TYPE
If YES, complete all sections and the New Provider questions.
If YES, complete *only* Sections 1, 2, 6 and 7 (as applicable).
  IDENTIFYING INFORMATION
  LICENSURE
Please include a copy of your CA Professional License, DEA License (if applicable) and Driver's License with this application. Acceptable formats: .jpg, .pdf. Max file size: 5,000 KB.
  PROFESSIONAL EDUCATION
  POST-GRADUATE TRAINING: INTERNSHIP(S)
  BOARD CERTIFICATION
  HEALTH STATUS
If the answer is NO to either of the following questions, please include details as an attachment. Acceptable formats: .jpg, .pdf. Max file size: 5,000 KB.
If "NO" or if reasonable accomodation is required, please explain in attachment.
If "NO" or if reasonable accomodation is required, please explain in attachment.
  DISCIPLINARY and/or VOLUNTARY ACTIONS
Have any of the following ever been, or are currently being denied, revoked, suspended, relinquished, withdrawn, reduced, limited, placed on probation, not renewed, or currently under investigation?
If “yes” please provide details on Attachment “A” – Malpractice Claims Questionnaire
  REQUEST TO PROVIDE VOLUNTARY SERVICES
By my signature below, I acknowledge that I have the burden of producing information requested by Coachella Valley Volunteers in Medicine for proper evaluation of my professional training, experience, competence, character, ethics and other qualifications and for resolving any doubts about such qualifications. I further acknowledge and agree that I will promptly and fully report all information to the CVVIM clinic in the event any of the answers above change, or if any situation arises which affects my ability to treat patients, after I have signed and dated this form. All the information contained in this application is complete and accurate to the best of my knowledge. I pledge that I am free from any chemical dependency and physically and mentally able to practice medicine and perform the volunteer services I have requested. I agree to abide by clinic policies and procedures as from time to time may be revised or enacted.
  CONSENT FOR RELEASE OF INFORMATION
I hereby authorize Coachella Valley Volunteers in Medicine or their representatives, to consult with any entities or persons that may have information relative to my professional practice. A photocopy of this waiver shall be as effective as the original when so presented. This consent shall remain in full force and effect for a period of two (2) years from the date signed below. I hereby release from any liability all those who, in good faith, review, act on, or provide information regarding my competence, training, experience, professional ethics, character, health status, and other qualifications, for providing volunteer services. I understand that the completion of this application is my sole responsibility. I declare that the information furnished by me in this application is true and correct to the best of my knowledge.
  ATTACHMENT "A": MALPRACTICE CLAIM | SUIT QUESTIONNAIRE(S)
If you answered YES to Question 12 of DISCIPLINARY and/or VOLUNTARY ACTIONS of this application, please complete the following questionnaire for EACH CLAIM or SUIT. If you need to report more than one incident, please upload this information in a .pdf. Maximum file size: 5,000 KB.
  SIGNATURE
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