Volunteer Registry

If you are interested in volunteering at the Free Clinic of Pierce and St. Croix Counties, Inc., please fill out the volunteer application below. The Free Clinic Steering Committee is currently in the process of gathering information and will contact you at a later date to discuss your application.

Position Descriptions:

Greeter

Nursing Care Professional

Volunteer Application

First name	Last name
Address/PO Box	Apt. or unit number
City	State
Zip code	Email
Phone number (home)	Phone number (work)
Phone number (cell)	Language Proficiencies

Which volunteer positions are you interested in?

Physician
Physician Assistant
Nurse Practitioner
Nurse
Medical Assistant
Social Worker/Intake worker
Pharmacist
Receptionist
Transcriptionist
Clerical worker
Bookkeeper
Interpreter
Other (please specify)

Please describe any medical training, experience or skills that would help you perform volunteer duties at the Free Medical Clinic.

Please describe other volunteer experiences you have had, including your responsibilities and any skills you may have.

Please describe any work or life experiences where you have interacted with diverse populations.

Please give two references for us to contact.

Name	Phone
Institutional Affiliation	Email

Name	Phone
Institutional Affiliation	Email