Personal Information

Name
MM slash DD slash YYYY
Address
Projects I’m Interested In

References

Name
Name
In accepting the position of a volunteer at Duffy Health Center, it is understood that all information concerning what occurs in my time here is held in the strictest confidence. I agree to uphold and respect this at all times, and I further understand that I could be dismissed for disregarding policies of confidentiality. I authorize Duffy to contact my references and process my CORI prior to making a final determination on my application. Volunteers who do not adhere to the policies of Duffy or who fail to satisfactorily perform their volunteer assignments are subject to dismissal.