Medical Professional Volunteer Application

Thank you for your interest in volunteering at Outside In!

To submit your application please complete the form below. Fields marked with a red asterisk * are required. Your information will not be saved until you click Submit at the bottom of this form. The application will take about 20 minutes to complete.


Personal Information

First name *

Last name *

Middle name

List all legal names

Preferred name

Preferred pronouns

Are you under 21? *

Date of birth *

Cell phone

Home phone

Street address *

City *

State *

ZIP/Postal code *

Email *


Emergency Contact Information

Name *

Relationship *

Emergency phone number *


How did you hear about us?

Specify source *


Availability

Can you commit 100 hours?

Date available to begin *

Last date available *

Availability *
Monday morningMonday afternoonTuesday morningTuesday afternoonWednesday morningWednesday afternoonThursday morningThursday afternoonFriday morningFriday afternoon

Maximum hours per week *


References

Reference 1

Reference name

Reference email

Reference phone

Relationship to applicant

Years known

Reference 2

Reference name

Reference email

Reference phone

Relationship to applicant

Years known


Employment/Volunteer Experience

Add résumé

Add any other relevant attachments

If you are currently employed, who is your employer?

Please list employment and volunteer experience starting with the most recent. *

What is your profession? *

Are you board certified? *

What is your specialty?

License number *

NPI number

If you do not have an NPI number, you may request one here.

Do you have admitting privileges at local hospitals? Not required.

Language proficiency


Background Information

If you have ever been a client with Outside In, when was the last time you received services?

At Outside In, our volunteers role model healthy behaviors. Please share your experience with drugs and alcohol below. Past issues are not an automatic disqualification from volunteering. *

Have you ever been convicted of a felony or misdemeanor that has not been expunged? If yes, provide details below. A conviction is not an automatic disqualification from volunteering.

Conviction *

Charges

Dates

Details


Volunteer Opportunities

Please select the position(s) that you are applying for below. Click here for volunteer opportunities.

Position *
Licensed AcupuncturistLicensed Massage TherapistPhysical TherapistPodiatristProject Erase Tattoo Removal Provider (MD, NP, ND, DO)


Questions

What motivates you to volunteer with an agency that serves homeless and low income youth and adults? *

Describe any experiences you have had with homelessness, street youth, drug affected individuals, community based clinics, or HIV related issues. *

Boundaries are the parameters that help keep relationships professional. Some of our clients have boundary issues with adults/authority figures. How might you respond to a client who asked you to take them home for dinner? *

Outside In is a clinic that provides options counseling (pregnancy, adoption, and terminations) as well as a full range of contraceptive care. Are you comfortable providing care at a clinic that provides these services? *

Outside In provides services to LGBTQIA+ (Lesbian, gay, bisexual, transgender, queer) clients. Do you feel comfortable working with these clients? *

What else would you like us to know about you? *


Application's Certification

In consideration of my service, I agree to conform to the instruction, rules and policies of Outside In. I understand that I may be terminated at any time and for any reason; with or without notice, at the option of Outside In.

I understand that as a condition of my service Outside In will conduct a pre-selection background investigation, driving history, identity, criminal history, reference, education, employment or personal check. I authorize Outside In to conduct any of these investigations and understand that the results of these may be used in the agency's selection decision.

I hearby acknowledge that I have read and understand the above statements. I certify that all answers to the questions in this application and all additional information I may have submitted are true and complete to the best of my knowledge. I understand that giving false information, misrepresenting facts, and material omissions may be grounds for denial of service or discharge.

Signature *