Volunteer Application
Personal Information
Name:
Address:
City:
State:
Zip:
Email:
Phone:
Age (You must be 14 years old to volunteer):
Emergency Contact
Name:
Address:
City:
State:
Zip:
Email:
Phone:
Relationship:
References
(no family or friends please)
Name:
Phone:
Relationship:
Name:
Phone:
Relationship:
Availability
When are you available to volunteer?
Mon
Tue
Wed
Thu
Fri
Sat
Sun
8:30-10:00 a.m.
10:00 a.m.-1:00 p.m.
1:00-4:00 p.m.
4:00-7:00 p.m.
Other availability or comments:
Service
Where would you like to volunteer?
Berea Primary Care Clinic
WHC - McKee
Nursing Home
WHC - Berea
WHC - Richmond
Other Events
How would you like to help? Please include any languages spoken, other talents, volunteer specifics, etc.
Criminal History
Have you ever been convicted of, or pled guilty to a crime?
No
Yes
If yes, please explain.
I understand and agree that submitting this application form does no automatically register me as a White House Clinics volunteer, and there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering. I understand and agree to have my references contacted.
By submitting this form, I attest that the information I have provided on the form is true and accurate. I understand that falsification of this or any other information is grounds for immediate termination.
I agree
WHC-McKee
WHC-Berea
WHC-Irvine
606-287-7104
859-986-2323
606-723-0665
Berea Primary Care Center
WHC-Richmond
859-985-1415
859-626-7700
Contact Us
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