Personal Information*Name*Address*Residency Full-time Resident Part-time Resident If part-time resident, what time of year do you reside here?*EmailHome Phone*Cell PhoneEmergency Contact Information*Emergency Contact Name*PhoneEmployment*Employment Status Employed FT Employed PT Retired FT Student PT Student *Current/Most Recent EmployerEducation*College/University*Major/Specialty*Graduation DateLicensed/Certified Professionals **Please attach a copy of license and/or certificationLicense Type and numberIf you are a MD, PA, DO or FNP you may attach a copy of your NC License, DEA and Malpractice Insurance Certificate here or mail to or bring copies by the Community Care Clinic. Please also attach any CPR, BLS or ACLS certifications.Has your professional license ever been restricted in any way? yes no If yes, please explain.Have you worked in a position in which you utilized your licensure/certification?If yes, list experience (where and dates)Misc. information*How did you find out about the Community Care Clinic?*Do you have any prior volunteer experience? If so, where did you volunteer and for how long?Volunteer Position Desired (Check all that apply) *position requires appropriate professional training or certificationClinical Volunteers Medical Provider* ( MD DO PA NP) Medical Intake*( RN LPN CNA EMT) Phlebotomist* Mental Health Counselor* Administrative Clerical/Office Assistant Data Entry/Scanning Special Projects Resource Volunteer Other Fundraising Publicity Board of Directors AvailabilityOur regular business hours are listed below, however; we may have special projects or events that occur outside these hours in which we may need volunteer support. Clinic Hours: *Mon – Thurs 8:45am–5pm *Tues evening: 5pm–8:30, Fri 8:45am-12pm*Please indicate which days and times you are available to volunteer(check all that apply)Monday 8:45am-12:30pm 1-5pm Other Tuesday 8:45am-12:30pm 1-5pm 5-8:30pm Wednesday 8:45am-12:30pm 1-5pm Other Thursday 8:45am-12:30pm 1-5pm Other Friday 8:45am-12:00pm *Frequency of Service 1X/Month 1X/Week 2X/Week Other *Time Commitment **Please note that a minimum time commitment of 3 months is required of all volunteers* 3 months 6 months 1 year More than 1 Year Other ReferencesPlease provide contact information for two people who can attest to your character and suitability for volunteer work at the Community Care Clinic. We will contact all references via email or phone. Fields with (*) are compulsory.