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