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678-625-8317

For life-threatening emergencies, call 911

Free medical care for

Newton, Jasper, and Walton Counties

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Volunteer Application

Please fill out the form below if you are interested in volunteering with Willing Helpers Clinic. We will get back with you within 24-48 hours with more information. Thank you for your interest in caring for our patients!

First name

Last name

Email

Phone Number

Address

Birthday (Month/Year)

Which position are you interested in?

Clerical

Spiritual Care

Medical

Other

Do you have any medical experience, trainings, certifications?

Are you a U.S. Citizen?

No

Yes

Have you ever been convicted of a felony?

No

Yes

If you answered yes to the last question, please elaborate:

Are you a current student? If so, what school?

Do you attend church regularly?

Yes

No

Employment/volunteer work experience (current and/or previous)?

Personal references (2 required with name, contact info, and relationship to applicant):

Electronic Signature - by typing your name below you agree that you have answered honestly and to the best of your abilities:

Thanks for submitting!

4186 Mill Street NE

Covington, GA 30014

678-625-8317

For Life-Threatening Emergencies Call 911

For I was sick and you looked after me... Matthew 25:35-36

Candid 2022 Platinum

© 2023 by Willing Helpers Clinic, a 501c3 non-profit organization.

EIN: 56-2602392

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