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 the following requirements. Please consider these requirements carefully before deciding to become a volunteer.

APPLICANT INFORMATION

Today's Date: *

First Name *

Last Name *

Street Address (Street Address including House or Apt Number, City, State and Zip Code): *

Phone (Primary Phone): *

Is this a cell phone? *

Yes

Phone (Secondary Phone):

Email *

Birthdate: *

Are you related to anyone who is a patient at CVVIM?

Yes

EMERGENCY CONTACT

Emergency Contact First Name *

Emergency Contact Last Name *

Emergency Contact Primary Phone: *

Emergency Contact Secondary Phone:

Relationship:

EDUCATION

Student: High School Health Academy

Yes

If YES, what school do you attend?

Student: College

Yes

If YES, name of college and Major Course of study:

Certification Practicum Extern

Yes

Highest Grade Level completed:

Certificates and/or Licenses Granted:

EMPLOYMENT

Are you Employed Full-Time?

Yes

If YES, is this a Charitable Match Program (Full-Time)?

Yes

If YES, who is your (Full-Time) employer?

Are you Employed Part-Time?

Yes

If YES, is this a Charitable Match Program?

Yes

If YES, who is your (Part-Time) employer?

AVAILABILITY

What day(s) are you available to volunteer?

Tuesday

Wednesday

Thursday

Friday

Saturday

Important:

Once your application is received, you will be contacted to move your application forward. You are NOT accepted as volunteer until several other steps have been completed: (1) You MUST reply to our voice or email contact within 15 days (failure to do so may result in your application being disposed of); (2) You are required to confirm your volunteer commitment, and; (3) You MUST arrange a shadow day.

Confirm you're a real person.

APPLICANT INFORMATION

EMERGENCY CONTACT

EDUCATION

EMPLOYMENT

INTERESTS

SKILLS

AVAILABILITY