Clinical Volunteer Application

Clinical Volunteer Application Form

Please complete this application form if you are interested in becoming a Clinical Volunteer at Global Health and Education, Inc. affiliated Charity Clinics. You must hold an active license through the Virginia Department of Healthcare Professionals. Once you complete this application form, click the submit button at the bottom.

First Name *

Last Name

Date of Birth *

Street Address *

City *

State/Province *

ZIP / Postal Code *

Country *

Phone Number *

Alternate Phone Number

Email Address *

Emergency Contact:- Name:

Phone Number

Relationship

License Information: We require the following information to provide you free Malpractice Insurance through Commonwealth of Virginia Local Government and Free Clinic Risk Management Plan.

Type of License ( choose): *

License Number: *

Initial issue Date

Expiration Date

DEN Number: *

Expiration Date

NIP Number: *

Join Hands: Empowering Lives, One Step at a Time

We would be happy to answer your queries and have all the discussions to make easy for you

Contact Info

GLOBAL HEALTH AND EDUCATION, INC

GLOBAL HEALTH AND EDUCATION, INC
210 RIVER'S BEND CIRCLE CHESTER, VIRGINIA 23836
+1 804-712-3873 (mobile)
+1 804-451-4460 (fax)
+1 804-451-3650 (office)
global.healthandwellnessclinic@gmail.com

ImportantLinks

GHE Clinic Address

Global Health and Wellness Clinic 4440 Springfield Road, Suite 101 Glen Allen, VA
23060
(To reschedule or cancel appointment, please text message to 804-712-3873)