Volunteer Application

Fill out the application below and send it to us at:

Moore Free Care Clinic
Volunteer Coordinator
P.O. Box 1656
Carthage, NC 28327-1656

Personal & Contact Information

Title:     Dr.     Mr.     Mrs.     Ms.     Rev.

First Name: ________________________ M.I. ____

Last Name: ________________________________

Nickname: _________________________________

Degree/Credentials: _________________________

Street Address: _____________________________

City: _________________ State: ___ Zip: ________

Home Phone: _______________________________

Work Phone: _______________________________

Fax: ______________________________________

Email: _____________________________________

For Students Only

College/High School: ________________________

Major: ____________________________________

Minor: ____________________________________

Service-Learning Student?   Yes   No

Expected Date of Graduation __________________

Faculty Advisor: ____________________________

Volunteer Information

a. Please check the areas in which you would like to volunteer:

b. List any skills or training that support your volunteer interests:
_______________________________________
_______________________________________

State briefly why you wish to volunteer for the Free Clinic:
_______________________________________
_______________________________________
_______________________________________
_______________________________________

List any other volunteer experiences you've had:
_______________________________________
_______________________________________
_______________________________________
_______________________________________

Please list the dates and times that you are willing to volunteer each week:

Comments:
_______________________________________
_______________________________________
_______________________________________
_______________________________________

How did you hear about volunteer opportunities in our organization?

Contact In Case of Emergency:

Name: __________________________________

Relationship: _____________________________

Address: ________________________________

Phone Number: ___________________________

Signature: __________________ Date: ________