Non-Provider Application

Date Submitted

MonthDayYear
Borland Free Clinic Non-Provider Application

Please complete all questions and be sure to click on the "Submit" button at the bottom of the application when finished. This form will take approximately 30 to 45 minutes to complete and your responses will be saved if you leave the form and come back later (on the same computer). Thanks for your interest in volunteer opportunities with the Borland Free Clinic.
General Volunteer Information
How did you hear about volunteering at the Borland Free Clinic?*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
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Date*

MonthDayYear
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Phone Number

Area CodePhone Number
Date

MonthDayYear
Date
Provide all other names that you have previously used:
Type a question

Type option 1Type option 2Type option 3Type option 4
Type a question
Type a question

Type option 1Type option 2Type option 3Type option 4
Applicant Signature:*
Date*

MonthDayYear
Type a question
How did you hear about volunteering at the Borland Free Clinic?*
Second Contact Name

First NameLast Name
ID Number*
First Contact Name

First NameLast Name
Government Issued ID Type*
Clinic Opportunities:*

FundraisingFront Desk RegistrationScribeSpanish InterpreterEvent PlanningPrayer TeamOther
Best Phone Number

Area CodePhone Number
What Language?
TB (PPD Skin) Test:*

I have had a TB test within the past year and it was negative. I will provide proof of this test upon request.I have had a positive TB test but have undergone or am currently undergoing treatment and have no symptoms. I will provide proof of treatment upon request.I have not had a TB test within the past year, but I will obtain one within one month of applying to volunteer. (Forms for free testing at any Legacy Lab are available at the clinic.)
Do you speak another language?

YesNo
Best Phone Number

Area CodePhone Number
COVID Vaccination:

I have had either both shots of the Pfizer or Moderna COVID vaccine, or one shot of the Johnson & Johnson COVID vaccine.I am not vaccinated for COVID, but will be as a condition of my volunteering at the clinic. (The Johnson & Johnson COVID vaccine is available free at the clinic.)I do not want to be vaccinated for COVID.
Proof of COVID Vaccination:

Browse Files

Cancelof
Certifications:

I certify that my PPD skin test was negative as of the date below. I currently have no symptoms of active TB disease. (Volunteers need to be tested for TB once a year. The testing is free for all BF volunteers.)I certify that I am PPD skin test positive and have had (or am currently undergoing) appropriate evaluation and/or treatment for my positive skin test. I currently have no symptoms of active TB disease.I certify that I have been vaccinated for Hepatitis B. The series of three injections was completed on or about the date shown below.I am in the process of having the Hepatitis B series of three injections completed. The anticipated date of completion is listed below. I understand that I cannot have direct patient care until this process is completed, but can work behind the scenes in the clinic on non-clinic days.I have not had the Hepatitis B series of three injections and choose not to participate in the treatment series.
Date of negative PPD skin test:

MonthDayYear
Date of birth*

MonthDayYear
Date of vaccination for Hepatitis B:

MonthDayYear
Date of completion of vaccination for Hepatitis B:

MonthDayYear
Phone Number

Area CodePhone Number
Name*

First NameLast Name
List all states (including counties) along with how long you've lived in each, for the past seven years:*
Browse Files

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Applicant Signature:*
Provide all other names that you have previously used:
Browse Files

Cancelof
Date*

MonthDayYear
Phone Number

Area CodePhone Number
Provide all other names that you have previously used:
Applicant Signature:*
How did you hear about volunteering at the Borland Free Clinic?*
Second Contact Name

First NameLast Name
List all states (including counties) along with how long you've lived in each, for the past seven years:*
ID Number*
How did you hear about volunteering at the Borland Free Clinic?*
Best Phone Number

Area CodePhone Number
Second Contact Name

First NameLast Name
First Contact Name

First NameLast Name
Clinic Opportunities:*

FundraisingFront Desk RegistrationScribeSpanish InterpreterEvent PlanningPrayer TeamOther
What Language?
Do you speak another language?

YesNo
Best Phone Number

Area CodePhone Number
Type a question
TB (PPD Skin) Test:*

I have had a TB test within the past year and it was negative. I will provide proof of this test upon request.I have had a positive TB test but have undergone or am currently undergoing treatment and have no symptoms. I will provide proof of treatment upon request.I have not had a TB test within the past year, but I will obtain one within one month of applying to volunteer. (Forms for free testing at any Legacy Lab are available at the clinic.)
Certifications:

I certify that my PPD skin test was negative as of the date below. I currently have no symptoms of active TB disease. (Volunteers need to be tested for TB once a year. The testing is free for all BF volunteers.)I certify that I am PPD skin test positive and have had (or am currently undergoing) appropriate evaluation and/or treatment for my positive skin test. I currently have no symptoms of active TB disease.I certify that I have been vaccinated for Hepatitis B. The series of three injections was completed on or about the date shown below.I am in the process of having the Hepatitis B series of three injections completed. The anticipated date of completion is listed below. I understand that I cannot have direct patient care until this process is completed, but can work behind the scenes in the clinic on non-clinic days.I have not had the Hepatitis B series of three injections and choose not to participate in the treatment series.
COVID Vaccination:

I have had either both shots of the Pfizer or Moderna COVID vaccine, or one shot of the Johnson & Johnson COVID vaccine.I am not vaccinated for COVID, but will be as a condition of my volunteering at the clinic. (The Johnson & Johnson COVID vaccine is available free at the clinic.)I do not want to be vaccinated for COVID.
Proof of COVID Vaccination:

Browse Files

Cancelof
Date of negative PPD skin test:

MonthDayYear
Date of completion of vaccination for Hepatitis B:

MonthDayYear
Date of birth*

MonthDayYear
First Contact Name

First NameLast Name
Name*

First NameLast Name
Date of vaccination for Hepatitis B:

MonthDayYear
Government Issued ID Type*
Clinic Opportunities:*

FundraisingFront Desk RegistrationScribeSpanish InterpreterEvent PlanningPrayer TeamOther
Best Phone Number

Area CodePhone Number
What Language?
TB (PPD Skin) Test:*

I have had a TB test within the past year and it was negative. I will provide proof of this test upon request.I have had a positive TB test but have undergone or am currently undergoing treatment and have no symptoms. I will provide proof of treatment upon request.I have not had a TB test within the past year, but I will obtain one within one month of applying to volunteer. (Forms for free testing at any Legacy Lab are available at the clinic.)
Do you speak another language?

YesNo
Best Phone Number

Area CodePhone Number
COVID Vaccination:

I have had either both shots of the Pfizer or Moderna COVID vaccine, or one shot of the Johnson & Johnson COVID vaccine.I am not vaccinated for COVID, but will be as a condition of my volunteering at the clinic. (The Johnson & Johnson COVID vaccine is available free at the clinic.)I do not want to be vaccinated for COVID.
Proof of COVID Vaccination:

Browse Files

Cancelof
Certifications:

I certify that my PPD skin test was negative as of the date below. I currently have no symptoms of active TB disease. (Volunteers need to be tested for TB once a year. The testing is free for all BF volunteers.)I certify that I am PPD skin test positive and have had (or am currently undergoing) appropriate evaluation and/or treatment for my positive skin test. I currently have no symptoms of active TB disease.I certify that I have been vaccinated for Hepatitis B. The series of three injections was completed on or about the date shown below.I am in the process of having the Hepatitis B series of three injections completed. The anticipated date of completion is listed below. I understand that I cannot have direct patient care until this process is completed, but can work behind the scenes in the clinic on non-clinic days.I have not had the Hepatitis B series of three injections and choose not to participate in the treatment series.
Date of negative PPD skin test:

MonthDayYear
Date of birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth*

MonthDayYear
Name*

First NameMiddle NameLast NameSuffix
Date of vaccination for Hepatitis B:

MonthDayYear
Cell Phone

Area CodePhone Number
Date of completion of vaccination for Hepatitis B:

MonthDayYear
Preferred Phone*

Area CodePhone Number
Date*

MonthDayYear
Type a question
E-mail*
COVID Vaccination:

I have had either both shots of the Pfizer or Moderna COVID vaccine, or one shot of the Johnson & Johnson COVID vaccine.I am not vaccinated for COVID, but will be as a condition of my volunteering at the clinic. (The Johnson & Johnson COVID vaccine is available free at the clinic.)I do not want to be vaccinated for COVID.
Date of vaccination for Hepatitis B:

MonthDayYear
Phone Number

Area CodePhone Number
Best Phone Number

Area CodePhone Number
Do you speak another language?

YesNo
Government Issued ID Type*
Proof of COVID Vaccination:

Browse Files

Cancelof
Best Phone Number

Area CodePhone Number
ID Number*
How did you hear about volunteering at the Borland Free Clinic?*
First Contact Name

First NameLast Name
What Language?
Second Contact Name

First NameLast Name
Certifications:

I certify that my PPD skin test was negative as of the date below. I currently have no symptoms of active TB disease. (Volunteers need to be tested for TB once a year. The testing is free for all BF volunteers.)I certify that I am PPD skin test positive and have had (or am currently undergoing) appropriate evaluation and/or treatment for my positive skin test. I currently have no symptoms of active TB disease.I certify that I have been vaccinated for Hepatitis B. The series of three injections was completed on or about the date shown below.I am in the process of having the Hepatitis B series of three injections completed. The anticipated date of completion is listed below. I understand that I cannot have direct patient care until this process is completed, but can work behind the scenes in the clinic on non-clinic days.I have not had the Hepatitis B series of three injections and choose not to participate in the treatment series.
Clinic Opportunities:*

FundraisingFront Desk RegistrationScribeSpanish InterpreterEvent PlanningPrayer TeamOther
Provide all other names that you have previously used:
TB (PPD Skin) Test:*

I have had a TB test within the past year and it was negative. I will provide proof of this test upon request.I have had a positive TB test but have undergone or am currently undergoing treatment and have no symptoms. I will provide proof of treatment upon request.I have not had a TB test within the past year, but I will obtain one within one month of applying to volunteer. (Forms for free testing at any Legacy Lab are available at the clinic.)
Date of negative PPD skin test:

MonthDayYear
Date of completion of vaccination for Hepatitis B:

MonthDayYear
Applicant Signature:*
Name*

First NameLast Name
Date of birth*

MonthDayYear
Name*

First NameLast Name
Browse Files

Cancelof
List all states (including counties) along with how long you've lived in each, for the past seven years:*
ID Number*
Current Occupation*
List all states (including counties) along with how long you've lived in each, for the past seven years:*
Browse Files

Cancelof
Date of Birth*

MonthDayYear
Name*

First NameMiddle NameLast NameSuffix
Cell Phone

Area CodePhone Number
Preferred Phone*

Area CodePhone Number
E-mail*
ID Number*
Current Occupation*
Type a question
Type a question
COVID Vaccination:

I have had either both shots of the Pfizer or Moderna COVID vaccine, or one shot of the Johnson & Johnson COVID vaccine.I am not vaccinated for COVID, but will be as a condition of my volunteering at the clinic. (The Johnson & Johnson COVID vaccine is available free at the clinic.)I do not want to be vaccinated for COVID.
Phone Number

Area CodePhone Number
ID Number*
Browse Files

Cancelof
Browse Files

Cancelof
Browse Files

Cancelof
Type a question
Browse Files

Cancelof
Emergency Contact Information
First Contact Name

First NameLast Name
Best Phone Number

Area CodePhone Number
Second Contact Name

First NameLast Name
Best Phone Number

Area CodePhone Number
Areas of Interest
Clinic Opportunities:*

FundraisingFront Desk RegistrationScribeSpanish InterpreterEvent PlanningPrayer TeamOther
Browse Files

Cancelof
Type a question
Browse Files

Cancelof
Do you speak another language?

YesNo
What Language?
Health Screening Information

A prerequisite to processing this application is that you have completed this form and all the screenings/vaccinations as indicated below (TB test must be current within 9 months of this application):
TB (PPD Skin) Test:*

I have had a TB test within the past year and it was negative. I will provide proof of this test upon request.I have had a positive TB test but have undergone or am currently undergoing treatment and have no symptoms. I will provide proof of treatment upon request.I have not had a TB test within the past year, but I will obtain one within one month of applying to volunteer. (Forms for free testing at any Legacy Lab are available at the clinic.)
COVID Vaccination:

I have had either both shots of the Pfizer or Moderna COVID vaccine, or one shot of the Johnson & Johnson COVID vaccine.I am not vaccinated for COVID, but will be as a condition of my volunteering at the clinic. (The Johnson & Johnson COVID vaccine is available free at the clinic.)I do not want to be vaccinated for COVID.
Proof of COVID Vaccination:

Browse Files

Cancelof
Certifications:

I certify that my PPD skin test was negative as of the date below. I currently have no symptoms of active TB disease. (Volunteers need to be tested for TB once a year. The testing is free for all BF volunteers.)I certify that I am PPD skin test positive and have had (or am currently undergoing) appropriate evaluation and/or treatment for my positive skin test. I currently have no symptoms of active TB disease.I certify that I have been vaccinated for Hepatitis B. The series of three injections was completed on or about the date shown below.I am in the process of having the Hepatitis B series of three injections completed. The anticipated date of completion is listed below. I understand that I cannot have direct patient care until this process is completed, but can work behind the scenes in the clinic on non-clinic days.I have not had the Hepatitis B series of three injections and choose not to participate in the treatment series.
Date of negative PPD skin test:

MonthDayYear
Date of vaccination for Hepatitis B:

MonthDayYear
Date of completion of vaccination for Hepatitis B:

MonthDayYear
Criminal History Screening Information & Consent

Please answer all questions below. Do not leave any areas blank. If information requested does not apply to you, answer by typing "NA" or "none" as applicable.
Name*

First NameLast Name
Date of birth*

MonthDayYear
List all states (including counties) along with how long you've lived in each, for the past seven years:*
Provide all other names that you have previously used:
Authorization to Release Information (Release from Liability and Waiver)

To any law enforcement agencies, civll records authorities and Borland Free Clinic: I authorize you to release to the Borland Free Clinic any and all information and civil or criminal records naming me, including all entries where I am named as being arrested, as a suspect, as being citied for any crime, violation, infraction or offense, or as otherwise involved or named in any report by any member agency of your organization.

The information that I have provided is accurate to the best of my knowledge and may be verified, if necessary by contacting persons or organizations named in this application, or by contacting any person or organization that may have information concerning me, or by conducting a criminal background check. I hereby release and agree to hold harmless from liabilityany person or organization that provides information. I also agree to hold harmless Borland Free Clinic and employees and volunteers thereof.
Applicant Signature:*
Date*

MonthDayYear
Enter the message as it's shown*

Borland Free Clinic Non-Provider Application

General Volunteer Information

Emergency Contact Information

Areas of Interest

Health Screening Information

Criminal History Screening Information & Consent

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