Volunteer Sign-Up

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How did you learn about volunteering at the Wausau Free Clinic? *

Friend

Newspaper

TV/Radio

Community Group

Website

Other

Check all education Completed

High School

Associate

College-Bachelors

Graduate Degree

I give my consent to a general background check, if required. *

Yes

No

Service Provider qualifications

MD/DO

PA

Pharmacist

Pharmacy Technician

NP/APN

Social Worker/Licensed MH Professional

N/A

Medical Intake/Discharge qualifications

RN

LPN

MA

Medical Student

Student Nurse

N/A

Clinic Support experience

Receptionist

Records Support

Social Support

Patient Advocate/Insurance Navigator

Marketing/Newsletters

Fundraising

Grant Writing

Computer Work

Direct Mailing

Reference - Personal *

First Name

Last Name

Reference - Personal *

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Reference - Professional *

First Name

Last Name

Reference - Professional *

(###)

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Please send a copy of any medical/health professional license to Jeff Todd at jeffreytodd2@gmail.com *

Yes, I sent it

No, I did not send it

N/A

I certify that the information contained in this application is true and complete to the best of my knowledge. I acknowledge that any misrepresentation, falsification or omission herein shall be sufficient reason for dismissal from or refusal of volunteer services. *

Yes

No