Volunteer form

Please mark “X” in the area in which you are licensed (1-6) or have an interest (7-9):

Health Care Professionals (1-8) must be licensed and/or certified in the state of Texas to practice at the Clinic. Please provide the following information:

Please indicate which languages you are fluent (F) or can communicate (C):

I authorize any inquiry to be made on any information contained in this application if I am considered for volunteer placement which could include a background check. I agree to abide by all staff and volunteer policies, including dress standards. I am willing to serve at a minimum of six (6) months after my on the job training. I understand I will serve two (2) three (3) hour shifts a month unless my duty assignment calls for a different schedule. I understand that all files and records maintained by the Greater Killeen Community Clinic are privileged and confidential. Any and all information that I may have access to may not be released or communicated to others unless authorized by the Executive Director or staff member who has also been authorized by the Executive Director to make that determination. I understand that I will be expected to treat all patients, volunteers and staff with respect. I understand and consent that any photos or video taken of me while at the Clinic can be used for Clinic purposes. I acknowledge my understanding of the conditions of my voluntary service for the Greater Killeen Community Clinic and acknowledge and understand that I must conform to the rules and regulations of the Greater Killeen Community Clinic to the best of my ability or my voluntary services may be terminated.