Become a VolunteerFill Out The Form BelowApplication FormPlease fill out this application form to be considered. First Name Last Name Personal Pronouns ---He/Him/HisShe/Her/HersThey/Them/TheirsOther, please specify Other Email Preferred method of contact Phone Email Position ---Student AdminMedical DoctorPhysician AssistantNurse PractitionerRegistered NurseBoard of DirectorsCommittee MemberLicensed Practitioner (ex: DC, LAc, LMT)CCP- w/ prior approval ONLY Please note that the "Student Admin" position is full. If you would like to be added to our wait-list, please submit an application. Thank you. Do you speak another language?     yes no If Yes, what language(s)? Do you have a projected end date for volunteering with us? Briefly state your reasons that you want to volunteer at the Ithaca Free Clinic? Provide a brief list of your experience: Phone Birthdate Emergency contact name Emergency contact phone # Have you worked with: Excel EHRs Google Drive Can you work during holiday breaks and/or during the summer?     yes no The clinic is open the following times, please indicate your availability. Mon 2-6 Tues 3-7 Th 3-7 other If "other", please write your availability: Please upload your resume & 3 references with contact information. *In .PDF format