People's Health Clinic

Volunteer Application

We prefer that all volunteers commit to helping weekly or, at a minimum, once a month. There is an online calendar to sign up for clinic dates and to check to see when we need volunteers. If you are unable to come when you are scheduled or must leave early or come late, please change the information on the calendar and notify the clinic Coordinator.

Complete this application & bring it by during Clinic hours (see Dates Available section). Or fax or send it and the Coordinator will contact you. (Print a copy of this application .)

Name__________________________________________________________________
Address_____________________________City_____________State_____Zip________
Home Phone_______________________Cell/work Phone_________________________
Email Address______________________________Birthdate_______________________

Dates Available (please check all that apply):
     Ö Tuesday (5-8 p.m.)
     Ö Wednesday (5-9 p.m.)
     Ö Thursday (5-8 p.m.)
     Ö In addition, please call me as a last-minute substitute

Volunteer Interest (please check all that apply):
     Ö Medical Provider (MD, PA, NP, etc.)
     Ö Intake
     Ö Vital Signs
     Ö Phlebotomy
     Ö Translator
     Ö Front Desk
     Ö Clerical

Please list any skills, certifications, training or language abilities:
_______________________________________________________________________
_______________________________________________________________________

Why do you want to volunteer with the People's Health Clinic?
_______________________________________________________________________
_______________________________________________________________________

Clinic Coordinator, People's Health Clinic
Box 681558, Park City, UT 84068
Phone: (435) 615-7822 Fax: (435) 615-7837