Description: This form is used to accept applications for volunteers at the Volunteers In Medicine Clinic. We thank you for your interest and participation. Directions: Fill in the information below. If necessary, use the scroll bar on the right to move down the page. When finished, click the Submit button located near the bottom of this form. If you are interested in volunteering at the Volunteers In Medicine Clinic, please fill out and submit the form below. NOTE: If you do not get a response within a few days please follow up with DeLeesa Meashintubby (Senior Operating Officer and Volunteer Director) at 541-686-3797 or email her at dmeashintubby@vim-clinic.org. 1. *Last Name:  2. *First Name:  3. Middle Initial:  4. *Street Address:  5. *City:  6. *State:  AL AK AZ AR CA CO CT DE DC FL GA HI IA ID IL IN KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY 7. *Zip Code:  8. *Daytime Phone:  9. *E-mail Address:  10. Age Range:  19-24 25-64 65 plus 11. Please describe your work history (include dates and positions, current and previous employment):  12. Briefly describe your community service, volunteer, or other experience:  13. Volunteer activity desired (please check all that apply):  To select multiple choices from the list below, hold down the CTRL key on your keyboard while clicking selections with your mouse. Nursing Pharmacy Social Services Clerical/Reception Medical Records Greeter/Reader Fundraising Special Projects Other Physician 14. I can work:  As needed--anytime One day per week Half day per week Two days per month 15. How many 4-hour shifts could you work per month?:  16. What hours of the day could you work?:  17. What days of the week could you work?:  18. Do you have computer skills?  Yes No 19. If yes to the above, please check all that apply:  To select multiple choices from the list below, hold down the CTRL key on your keyboard while clicking selections with your mouse. Word Excel Microsoft Office Lastword IDXtend 20. Do you have experience with other computer programs (please describe)?:  EDUCATION 21. Undergraduate school:  22. Specialty certifications currently held (i.e., BLS, ACLS, etc.):  In case of an emergency, whom should we contact? 23. Emergency Contact Name:  24. Emergency Contact Relationship:  25. Emergency Contact Phone Number:  26. Do you have any physical limitations that might affect the work you do at VIM?  Yes No 27. If "Yes" to the above, please explain:  PROFESSIONAL REFERENCES 28. Name #1:  29. Relationship #1:  30. Phone #1:  31. Name #2:  32. Relationship #2:  33. Phone #2:  (Click Submit to send this form)

Return to Positions at VIM.