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

Phone

Address (Street, City, State, Zip)

Birthday

Which position are you interested in?

Clerical

Spiritual Care

Medical

Other

Are you a U.S. Citizen?

Yes

Have you ever been convicted of a felony?

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

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!

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Email Address

First Name

I am a supporter of the clinic

Last Name

I am a current or future patient

Thanks for joining our newsletter! We'll be in touch soon!

4186 Mill Street NE

Covington, GA 30014

678-625-8317 phone

833-973-6162 fax

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For Life-Threatening Emergencies Call 911

EIN: 56-2602392

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