Volunteer Application

First Name:

M.I.:

Last Name:

Nickname:

Degree/Credentials:

Street Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Fax:

Email:

College/High School:

Major:

Minor:

Service-Learning Student?

Expected Graduation Date:

Faculty Advisor:

Volunteer Information

a. Please check the areas in which you would like to volunteer:

b. List any skills or training that support your volunteer interests:

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:

Comments:

How did you hear about volunteer opportunities in our organization?

Contact In Case of Emergency:

Name:

Relationship:

Address:

Phone Number: