First Name

Last Name

Email

Preferred method of contact  Phone Email
Position ---Medical DoctorPhysician AssistantNurse PractitionerRegistered NurseBoard of DirectorsCommittee MemberLicensed Practitioner (ex: DC, LAc, LMT)CCP- w/ prior approval ONLY

*The Student Admin position is no longer available, please contact us in December for the following semester. 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 none of the above
If none of the above, please write your availability:





Please upload your resume & 3 references with contact information.
*In .PDF format