Volunteer Application

We appreciate your interest in volunteering at the Downtown Clinic. Community volunteers founded our organization and keep it alive today!

Please check our vaccination policy, volunteer opportunities, and volunteer handbook before completing the form below:

We have currently reached our volunteer capacity for the following roles: reception/general, pharmacy assistant, garden, and intake during the summer. If you are interested in these volunteer positions, please apply in August when we will have more opportunities available. Thank you for your understanding!

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date of Birth

YYYY

What volunteer opportunities are you interested in?

Reception/General

Pharmacy Assistant

Garden

Intake (CNA/EMT/RN license required)

Nursing (RN/LPN or above required)

Healthcare Provider (FNP,APRN, MD required)

Pharmacist (PharmD required)

Medical Interpretation

Other

Education

Please include Educational Facility, Degree, and Years of Attendance for each school attended

Experience

Please list experiences that qualifies you for this work -volunteer/employment) Include: Employer, Position, and Years Employed.

Do you have or willing to get the necessary vaccinations to volunteer in our healthcare setting?

See vaccination requirements above. We will ask for proof of vaccinations.

How do you values or ethics align with the Downtown Clinic's mission?

Do you have any limitations you would like us to be aware of?

Due to the nature of our Clinic, we want volunteers are available to volunteer at least for 3 months or more. Would this be a time frame you are able to commit to?

By writing my name below:

I certify the above information is true. I give the Downtown Clinic permission to look up my vaccination records in the State of Wyoming (Out of state records must be emailed to laramiedtc@gmail.com) If accepted as a volunteer for a licensed professional position, I give permission for the Downtown Clinic to verify my license with the State Board of Licensure.

Date

YYYY

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Volunteer Application

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