Volunteer Application

Name *
Name
Phone *
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

Contact Elizabeth Daniel, Director of Community Outreach, with questions:  edaniel@alliancemedicalministry.org or (919) 250-2230 ext. 418.