Centre Volunteers in medicine

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For Volunteers

Apply to Volunteer Today

1. Complete a volunteer application online below.

If you prefer, you can download and print a volunteer application and mail your completed application to Sue Miller, our Volunteer Coordinator.

2. Attend a short orientation session to learn more about CVIM and the different areas where you can volunteer,
as well as receiving information and training about volunteering at a medical services organization.

We look forward to hearing from you soon!


Online Volunteer Application
(*) Required Fields
Last Name	First Name		Title	Date (mmddyyyy)
*	*			- - *
Local Address				Phone
*				( ) - *
City	State	Zip		Cellular/Pager
*	*	*		( ) -
Are you a student? If yes, Graduation Date:				Email
RSVP Member				*
Occupation				May we contact your employer to verify your professional license and credentials?

Employer
				Yes No N/A
Work Address				Work Phone
				( )
City	State	Zip		Fax
				( )

Volunteer Interests
Clinical Services Social Services/Eligibility Dental Services Special Events/Development Administration/Office				Community Relations Data Entry Reception Greeting Medical Records
What attracted you to Centre Volunteers in Medicine?*

Have you had a PPD (Tuberculosis) test in the past year?.*
Yes No

Clinical Volunteers: Have you been vaccinated against Hepatitis B? This is optional.
Yes No

Do you require any accommodations in order to perform the duties of a volunteer in the position for which you are volunteering? Yes No If yes, please explain:

Have you been convicted of a felony within the past five years?** Yes No If Yes, please explain:

**Note: A conviction will not necessarily bar you from volunteering. Each conviction is judged on its own merits with respect to time, circumstances, and seriousness.

Clinical Volunteers Only: Have you ever been required by any licensing board or professional ethics body to surrender your license, or have you ever been found guilty of professional ethics codes, professional misconduct, unprofessional conduct, incompetence or negligence, in any state or country?
Yes No If Yes, please explain:


Volunteer Agreement
I shall keep confidential all information that I obtain regarding patients, staff, and volunteers. I shall submit to any immunizations that may be a necessary part of my volunteer service. I shall be punctual and conscientious, conduct myself with dignity, courtesy and consideration of others, and endeavor to make my work professional in quality. I agree to resolve any problems that may arise with the Volunteer Coordinator. I shall make my best effort to fulfill my commitment to the Clinic by volunteering at least four hours per month and by completing all assignments that I accept. I shall at all times uphold the philosophy and standards of the Clinic. I understand that the Volunteer Coordinator reserves the right to terminate my volunteer status as a result of: Failure to comply with clinic policies, rules, and regulations. Absences without prior notification. Unsatisfactory attitude, work, or appearance. Any other circumstances, which in the judgment of the Clinic staff would make my continued service as a volunteer contrary to the best interests of the Clinic. I have read each of the above conditions and agree to be bound by them. I certify that the information I have given is complete, true and correct to the best of my knowledge and belief. I further affirm that I have not knowingly withheld any facts or circumstances in completing this application.

I agree to the terms stated above.
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Apply to Volunteer Today

Online Volunteer Application