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CLINIC VOLLUNTEER PROGRAM APPLICATION

Applications are being accepted from 1/1/08 through 2/11/08.
NOTE: Applications submitted prior to 1/1/08 must be re-submitted for consideration.

Clinic Volunteer Course Objective
To train students to work in University Health Services Clinical Services Department providing assistance to clinic staff in the primary care of patients in a sensitive and professional manner.

General Information
Note: You must complete all of the fields on this application
in order to be considered for this service learning program.

I am: FR / SO / JR / SR

First Name:

Last Name:

Birth Date:

PSU ID#:

Local Address:

City:

State:

Zip Code:

Local (or Cell) Phone:

Campus E-Mail:

Permanent Street Address:

Hometown/City:

State:

Zip Code:

Home Phone:

Other E-Mail:

Major:

Semester #: Proposed Year of Graduation:

Other Information

How did you learn about the Clinic Volunteer Program?

Please list the best times for us to contact you.

Day:

Time:

Day:

Time:

Please answer the following questions.

1. Why are you interested in becoming a Clinic Volunteer?

2. Describe special skills that you could bring to the clinic setting.

3. What relevant course work or education have you had?

4. What are your plans following graduation?

5. Describe past and present volunteer work, leadership positions or student organization you have participated in.

6. If selected into the Clinic Volunteer Program, would you be able to commit to one four-hour block of time each week each semeter to work in the clinic, plus attend the required weekly two-hour classroom training in the fall?

Yes
No

7. Is there anything else you would like us to know about you?

Reference: Please give us the name and phone number of someone who could serve as a reference for you. This should be a person who can speak about your abilities as a worker or employee, or with whom you have worked on academic or other projects, such as a professor, a teaching assistant, or your advisor.

Reference Name:

How they know you:

Reference's Address:

Reference's Phone Number:

What do you anticipate your reference will say about you?

Agreement

By submitting this form electronically, I agree that to the best of my knowledge
all of the above information is correct.

Any questions regarding your application may be directed to Joan Donahey, LPN
at (jzd7@psu.edu) or call (814) 865-6557

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CLINIC VOLLUNTEER PROGRAM APPLICATION

Applications are being accepted from 1/1/08 through 2/11/08. NOTE: Applications submitted prior to 1/1/08 must be re-submitted for consideration.

Clinic Volunteer Course Objective To train students to work in University Health Services Clinical Services Department providing assistance to clinic staff in the primary care of patients in a sensitive and professional manner.

Applications are being accepted from 1/1/08 through 2/11/08.
NOTE: Applications submitted prior to 1/1/08 must be re-submitted for consideration.

Clinic Volunteer Course Objective
To train students to work in University Health Services Clinical Services Department providing assistance to clinic staff in the primary care of patients in a sensitive and professional manner.