Volunteer Application – Duffy Health

Personal Information

Name

First Last

Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Emergency Contact

Phone

Please briefly explain why you would like to volunteer at Duffy

Please describe your interests, work experience and areas of expertise

Projects I’m Interested In

Promotion/Marketing

Community Organizer

Administrative Support

Committee Member

Professional Service

References

Name

First Last

Phone

Name

First Last

Phone

Signature

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.