Our Volunteer Application at the Moore Free Care Clinic

Moore Free Care Clinic, Helping Hands, Caring Hearts.

Volunteer Application

Fill out and submit the online application below, or
fill out the printable application and send it to us at:

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

Phone: (910) 947-6550
Fax: (540) 947-6551
Email: Volunteer@moorefreecare.org

Title:

Dr.

Mr.

Mrs.

Ms.

Rev.

First Name:

M.I.:

Last Name:

Social Security Number:

(xxx-xx-xxxx)

Nickname:

Degree/Credentials:

Street Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Fax:

Email:

* email address required

For Students Only

College/High School:

Major:

Minor:

Service-Learning Student?

Yes No

Expected Graduation Date:

Faculty Advisor:

Volunteer Information

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

Medical Program Staff

Pharmacy Program Staff

General Office Staff/Receptionist

Finance Specialist

Data Entry Clerk

Eligibility Reviewer

Housekeeper

Interpreter and translator

Computer Software/ Hardware Support

Health and Resource Educator

Public Relations/ Events/ Exhibits

Volunteer Coordination

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:

	Mon.	Tues.	Wed.	Thurs.	Fri.	Sat.	Sun.
AM
PM

Comments:

How did you hear about volunteer opportunities in our organization?

Friend

Newspaper

Clinic website

Relative

Newsletter

Staff

Professor

Other:

Contact In Case of Emergency:

Name:

Relationship:

Address:

Phone Number:

We are respectfully requesting that you submit the names and contact information for two non-relative references:

Reference One:

Reference Two:

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