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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 through the provision of primary medical 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 of 2 shifts (4-hour shifts) per month
for an initial three-month period. Before receiving a volunteer assignment, each candidate must complete:
• Be at least 18 years old.
• A personal interview.
• Authorize a background check. We ask for a $10 donation to offset expense.
• Orientation & Training.
• Maintain proper dress code: VIM polo ($20) or scrubs. No ripped or low rise jeans.
• Bilingual preferred (Spanish speaking).
•
COVID vaccine required (or in process).
Please consider these requirements carefully before deciding to become a Volunteer.
GENERAL VOLUNTEER APPLICATION
Today's Date
*
Last Name
*
First Name
*
Street Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Phone Number:
*
Cell Phone Number:
Email
*
Email
Confirm Email
EMERGENCY CONTACT INFORMATION
Name | Emergency Contact
*
Relationship (select one):
*
Spouse | Wife
Spouse | Husband
Domestic Partner
Friend
Relative
Relationship (Relative):
*
Sister
Brother
Aunt
Uncle
Cousin
Prefer not to say
Primary Phone Number | Emergency Contact:
*
Alternate Phone Number | Emergency Contact:
Are you currently (check all that apply):
*
Student | College
Certification Practicum Extern
Employed | Full Time
Employed | Part Time
Unemployed
Retired | Industry
Other (explain):
Employed | Full Time: Name of Employer
*
Charitable Match Program? (Employed Full Time)
YES
NO
Employed | Part Time: Name of Employer
*
Enter your Employer's Name if currently employed part-time.
Charitable Match Program? (Employed Part Time)
YES
NO
Retired | Industry
*
Other (explain):
*
EDUCATION
Certificates | Licenses Granted:
*
SHIFT AVAILABILITY
TUESDAY
08:30AM - 12:30PM
12:30PM - 05:00PM
Not available
WEDNESDAY
08:30AM - 12:30PM
12:30PM - 05:00PM
05:00PM - 09:00PM
Not available
THURSDAY
08:30AM - 12:30PM
12:30PM - 05:00PM
Not available
FRIDAY
08:30AM - 12:30PM
12:30PM - 05:00PM
Not available
SATURDAY
07:30AM - 01:00PM
Not available
VOLUNTEER ACTIVITY DESIRED AT CVVIM
Volunteer Activity Desired at CVVIM:
Front Office | Reception
Back Office: MA | EMT | LVN
Medical Translator | Spanish
Medical Scribe
Community Outreach
Health Fairs
Data Entry
Fundraising | Special Events
Back Office (MA, EMT, LVN): Certificate or License Required
Medical Scribe: Experience Required
Please review your form to be sure all questions have been answered.
Click SUBMIT to send your form.
SUBMIT