Name: Date of Birth:
Home Telephone: Best Time to Call:
Work Telephone: Best Time to Call:
Occupation/Previous Occupation:    
In Case of Emergency Contact: Relationship:
Emergency Contact Address:    
Emergency Contact Telephone:    
Check each box when available
Day Morning 9A-12N Afternoon 12N-4:30 PM Evening 5P-9P

Check all that apply

 1.  Nursing – Lic # 9.  Recruiting other volunteers
2.  Physician – Lic # 10.  Patient Registration
3.  Pharmacist – Lic # 11. Pharmacy Asst.
4.  Dentist – Lic # 12.  Dental Assistant
5.  General Office (typing, filing, computer) 13. Interview Patients/Screening
6.  Medical Referrals (Specialist appts.) 14.  Driver
7.  Computer Operator 15.  Building Repair and Maintenance
8.  Dinners (Provide meals for volunteers on clinic evenings) 16.  Other
Experience:  Please indicate any previous work    
List any previous experience in volunteer organizations:    
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Confidentiality Agreement
(Volunteers are asked to sign the following agreement)
1. Confidentiality is a MUST concerning patients and their medical records. You and the Clinic are liable and can be sued for any violation of this ethic.
2. Any specific medical questions the patient may ask should be referred to the medical staff. You may NOT recommend a specific physician or give your medical opinion to any patient or staff member.
3. You CANNOT share any information regarding any patient with another volunteer or ANYONE inside or outside the Clinic.

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Northern Neck Free Health Clinic  51 William B. Graham Court, Kilmarnock Virginia 22482
Telephone: (804) 435-0575 Fax: (804) 435-9017
E-Mail: info@nnmfhc.org