| Ph: 540.381.0820 Fax: 540.382.3391 |
215 Roanoke Street Christiansburg, Virginia 24073 |
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Volunteer ApplicationFill out the application and send it to:Free Clinic of the NRV Phone: (540) 381-0820 Personal & Contact InformationTitle: Dr. Mr. Mrs. Ms. Rev. First Name: ________________________ M.I. ____ Last Name: ________________________________ Nickname: _________________________________ Degree/Credentials: _________________________ Street Address: _____________________________ City: _________________ State: ___ Zip: ________ Home Phone: _______________________________ Work Phone: _______________________________ Fax: ______________________________________ Email: _____________________________________ For Students OnlyCollege/High School: ________________________ Major: ____________________________________ Minor: ____________________________________ Service-Learning Student? Yes No Expected Date of Graduation __________________ Faculty Advisor: ____________________________ Volunteer Informationa. Please check the areas in which you would like to volunteer:
State briefly why you wish to volunteer for the Free Clinic: List any other volunteer experiences you've had: Please list the dates and times that you are willing to volunteer each week:
How did you hear about volunteer opportunities in our organization?
Contact In Case of Emergency:Name: __________________________________ Relationship: _____________________________ Address: ________________________________ Phone Number: ___________________________ Signature: _______________________________ Date: ________ Please return to:Free Clinic of the NRV Phone: (540) 381-0820 |
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