Non-Provider Application

Date Submitted

Month Day Year

Name *

First Name Middle Name Last Name Suffix

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Preferred Phone *

Area Code Phone Number

Cell Phone

Area Code Phone Number

E-mail *

Date of Birth *

Month Day Year

Government Issued ID Type *

ID Number *

Current Occupation *

How did you hear about volunteering at the Borland Free Clinic? *

First Contact Name

First Name Last Name

Best Phone Number

Area Code Phone Number

Second Contact Name

First Name Last Name

Best Phone Number

Area Code Phone Number

Clinic Opportunities:

Do you speak another language?

Yes No

What Language?

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:

Month Day Year

Date of vaccination for Hepatitis B:

Month Day Year

Date of completion of vaccination for Hepatitis B:

Month Day Year

Name

First Name Last Name

Date of birth

Month Day Year

List all states and duration where you have previously lived in the last 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

Month Day Year

Enter the message as it's shown *

Borland Free Clinic Non-Provider Application

General Information

Emergency Contact Information

Areas of Interest

Health Screening Information

Criminal History Screening Information & Consent