Volunteer Application

Your Name (required)

Address (required)

City/State/Zip (required)

Your Email (required)


Phone Number (required)

Emergency Contact Name (required)
Emergency Contact Phone (required)
Emergency Contact Relationship (required)

Highest level of schooling completed (required)

Last Three Employers:

Most Recent Employer Name
Phone number
Dates employed:

Employer Name
Phone number
Dates employed:

Employer Name
Phone number
Dates employed:

I am interested in becoming:  a Heartland volunteer a Heartland food pantry volunteer a Resource Specialist in the Heartland food pantry an AmeriCorps member

Two references (required):

Phone Number
Phone Number

Check blocks of time available to serve:
Monday:  8:30-12:30 1:15-5:30
Tuesday:  8:30-12:30 1:15-5:30
Wednesday:  8:30-12:30 1:15-5:30
Thursday:  8:30-12:30 1:15-5:30
Friday:  8:30-12:30 1:15-5:30
Saturday:  8:30-12:30 1:15-5:30

Are you CPR certified?
 Yes No

Do you have previous volunteer experience?

What is the reason you wish to volunteer at Heartland Community Health Center? How long do you expect to volunteer?

What do you think you will gain from volunteering here?

In what ways are you a leader? Describe your leadership experience.

Where did you hear about us?

What are you studying (if you are in school)? What are your career goals?

Do you have a current resume? If so, please include.


Heartland Community Health Center Confidentiality Policy

Access to Confidential Records

In order for Heartland to provide a responsible and professional service to patients, it is necessary for patients to divulge extensive personal information. The clinic respects the confidentiality of patient records and with the exceptions of situations listed below, shares information about patients only among the professional medical staff. The right of confidentiality applies not only to written records, but also to video, film, pictures or the use of apatient’s name in agency publications

All records are considered the property of the clinic and not the clinic staff, volunteers or patients. In order to provide a service in the patient’s self-interest, outside medical records may also be assessed. Records are not available for review by patients.

Limits of Confidentiality

1. Information will be released to other medical personnel only upon presentation of an authorized ‘Consent to Release Information’ form appropriately signed by the patient.

2. Only authorized members of the medical staff will have access to files to assess and evaluate the performance of the clinic.
3. Information shall only be provided to law enforcement officials of the courts pursuant to a valid and enforceable subpoena. All volunteers and staff are responsible for staying abreast of such reporting requirements of the law and shall always comply with mandated procedures.
4. Information shall be provided to clinic legal counsel in the event of litigation or potential litigation involving the clinic.
5. If the clinic staff and/or volunteers receive any information indicating that a patient may be dangerous to him or her self or to others, necessary steps may be taken to protect the appropriate party.

I have read and understood the above document which states the clinic policy with respect to confidentiality of patient records. I agree to program participation under the conditions set forth.

• Volunteers are required to perform administrative duties as well as clinic support.
• Volunteers seeking a letter of recommendation are required to volunteer for a minimum of two semesters of service prior to consideration for recommendation eligibility.

I agree to these confidentiality terms

Heartland Community Health Center Statement of Faith

Heartland's staff and leadership believe in Christian principles.

As a volunteer in the Heartland, I pledge to support the staff and leadership who follow these beliefs. I will not undermine these beliefs in any way. If questions of philosophy, theology or ethics should arise with any patient, I will refer the patient to one of the staff members.

Mission Statement: To transform the health and lives of those in need through the love of Jesus Christ

Volunteer Responsibilities:

Volunteers may be asked to work in various programs, such as the Early Detection Works, Diabetes Care and Prevention, Meds by Mail, or food pantry. Heartland reserves the right to dismiss any volunteer from duties as a volunteer. Volunteer duties may include any or all of the following and other duties as needed:

• Assembling patient registration materials
• Waiting room maintenance and straightening
• Side-work, including restocking and trash

• Pharmacy inventory, stocking and maintenance
• Exam room maintenance, restocking and cleaning
• Getting medicines and instructions ready for patients

Please provide us with a copy of your medical insurance card and your immunization record. All medical volunteers must be immunized against Hepatitis B and must have had a tuberculosis test within the last year. Completion of Hepatitis B immunizations and tuberculosis test are required before volunteering.

I have read, understand and agree to these statements.