Volunteer Application

Name *
Mobile Phone *
Mobile Phone
If employed, please provide job title and company. If student, please provide where and what year in school.
Volunteer Interest *
Select all that apply.
Please provide if applicable: Professional License Number Copy of Malpractice Coverage Copy of DEA Certificate Copy of Privilege License
Preferred Volunteer Frequency *
Preferred Time of Day *
Preferred Days of Week *
Are you fluent in a second language? Please let us know proficiency and language below.
Please provide us your volunteer background, particularly in a clinical setting if interested in clinical volunteer opportunities.
Street or PO Box, City, State & Zip Code

Questions? Contact our Volunteer & Community Outreach Coordinator, Ruthie Wofford, at rwofford@alliancemedicalministry.org.