Free Clinic:  804-556-5840    |    Family Services:  804-556-6260

Volunteer Application for Interns and Students

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Volunteer Application for Interns and Students

Volunteer Application for Interns
Thank you for your interest in volunteering at Goochland Free Clinic and Family Services! We are pleased to partner with you as you complete your internship.

City
State
ZIP
Clinic volunteers and volunteers who provide direct client service must be 18 years old and no longer in high school.

When are you available to volunteer?

Check all that apply.
Tuesday evening = Clinic only
Wednesday evening = Clinic only

What program(s) would you like to volunteer in?

What type of skills and experience do you have?

Please include any skills or certifications (i.e. Spanish interpreter, CDL, CPR, electrician, contractor, etc.) you have and describe your volunteer experience.

How did you hear about Goochland Free Clinic and Family Services?

Why do you want to volunteer at Goochland Free Clinic and Family Services?

Who should we contact in case of an emergency?

Confidentiality Agreement

By submitting this volunteer application, I agree to adhere to the following policies: ACCESS TO and PROTECTION of CONFIDENTIAL INFORMATION During the course of volunteering, Volunteer will have access to certain personal and valuable information of the residents of Goochland County. Such information includes, but is not limited to, personal information about the residents of the county, including medical and dental conditions, history, prescriptions, employment and financial data and other similar personal information. (Such information collectively is the “Confidential Information.”) Volunteer acknowledges and agrees that all of the Confidential Information is strictly confidential. No reference shall be made inside or outside the organization about a client’s identity, diagnosis, treatment or other confidential information about the client. This includes verifying if a person has been seen by GFCFS and giving information to the parent of a child 18 years or older. I represent that I am competent to contract and have read and fully understand the contents, impact and meaning of these policies.

Publicity Release

Do you give permission to Goochland Free Clinic and Family Services and its licensees and assigns to photograph me, and to publish, transmit and share in any form of media my photographs and any information based on interviews that I have given?
Goochland Free Clinic and Family Services provides equal opportunities without regard to race, color, gender, national origin, religion, sexual preference, age or disability.
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