Medical Volunteer Application | Volunteer Health Organizations

Applicant Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State/Province/Region ZIP/Postal Code Country

Contact Information

Office Phone

Cell

Email(Required)

Educational Background

Highest Degree Attained

Other Highest Degree Attained

Academic Year

Employment Background

Please complete with current/most recent employer for the last 3 years.

Medical Affiliation Group (if any)

Employer #1

Employer Name

Employer Phone

Position

Length of Time

Primary Responsibilities

Employer #2

Employer Name

Employer Phone

Position

Length of Time

Primary Responsibilities

Employer #3

Employer Name

Employer Phone

Position

Length of Time

Primary Responsibilities

Skills & Interest

Do you speak a language other than English? If so, please list.

How did you learn about Fresh Start?

Please describe how we could best use your skills and talents to form an enriching and lasting volunteer relationship.

Please mark your area(s) of qualification(s). Check all that apply:

Anesthesia Support

Anesthesiologist

Auditing and Root Cause Analysis Support

Case Management

Circulator

Data Analysis - Case Type, Diagnosis, Cost and Income - Excel and Pivot Tables

Dental Clinics

Dentist

Evidence-Based Protocol and Policy Design

Interpreter

Medical Assistant

Ortho RDA

Overnight Caregiver

Physician Assistant

Pre-Op Nurse

Quality Outcomes/Continuous Improvement

RDA

RDH

Recover/PACU

Scrub Nurse/Tech

Speech Clinics

Speech Pathologist

Surgeon

Surgery Weekends

Other

Other qualification(s)

Health Background

Health-related issues

Are there any health-related issues that may limit your availability to volunteer?

Yes

If yes, please describe:

Electronic Signature

Electronic Signature(Required)

By checking this box, I certify that all information stated in this application is true and complete. I understand that any false information or omission may disqualify me from further consideration as a volunteer and may result in immediate dismissal if discovered at a later date. I authorize and release personal references, employers (past and present) and, if necessary, other applicable entities to answer questions regarding my volunteer work, employment, ability, character, medical and emotional background and, if applicable, driving history.

I accept(Required)

Full Name(Required)

Licensed Medical Volunteer Application

The following form is for LICENSED MEDICAL VOLUNTEERS ONLY in San Diego.