Volunteer Application VOLUNTEER APPLICATION Volunteer Application Please fill in the following application and hit "Submit" at the bottom of the application to send it to New Hope Clinic. A NHC representative will contact you shortly after receiving the application.Name *(Preferred for name badge) Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryEmail *Phone (Home) Phone (Work) Phone (Cell) Preferred Method of Contact EmailHomeWorkCellIn Case of Emergency Please Notify *Relationship to Volunteer Phone *Professional License in NC? YesNoType License Number How did you hear about New Hope Clinic? Previous Experience: Career/Personal (Employer, title, dates, duties) *How would you like to help? Front Office Administration (Reception)Back Office AdministrationMedical Records ClerkIT SpecialistInterpretingBuilding & Grounds (Landscaping)Building & Grounds (Repairs)Patient EligibilityMarketing/Social MediaDesign (newsletters/brochures)/ WebsiteCommunity Outreach/Public RelationsFundraising/Grant WritingVolunteer ManagementPractitioner: Primary Care or SpecialtiesNursing (Licensed)Unlicensed Assistive Personnel (EMT, RN/LPN with inactive license, Medical Assistant)PharmacistPharmacy TechnicianDentistDental Assistant/Hygienist/Lab TechnicianPatient Health EducationOther When would you like to volunteer? MorningAfternoonEveningSpecial EventsMondaysTuesdaysWednesdaysThursdaysFridaysPlease list two referencesName Phone Email Relationship to Volunteer Name Phone Email Relationship to Volunteer VOLUNTEER APPLICATION AGREEMENT 1. I certify that my answers on this application are true. 2. I authorize New Hope Clinic to verify the information submitted in this application and to contact the references provided. 3. If accepted as a volunteer at New Hope Clinic, I agree to abide by the rules and regulations of New Hope Clinic, Inc. 4. My services are donated without contemplation of compensation or future employment. 5. I shall not solicit any business for attorneys or insurance companies “for compensation”, both on or off Clinic property, or act as a runner for an attorney in the solicitation business. I shall report all known occurrences of solicitation for attorneys. 6. I shall not sell or attempt to sell goods or services, request contributions, or solicit persons to sign or distribute political petitions on Clinic premises. 7. I shall attempt to resolve any problems related to my volunteer activities with the New Hope Clinic Executive Director. 8. I understand that the Clinic reserves the right to terminate my volunteer status as a result of (a) failure to comply with Clinic policies, rules and regulations; (b) absences without prior notification; (c) unsatisfactory attitude, work, or appearance; or (d) any other circumstances which, in the judgment of the Executive Director, Medical Director, Dental Director, or Pharmacy Director, would make my continued service as a volunteer contrary to the best interests of the Clinic.I have read each of the above conditions and I agree to be bound by them. By checking this box I am agreeing to the terms of the volunteer application agreement. VerificationPlease enter any two digitsExample: 12This box is for spam protection - <strong>please leave it blank</strong>: