Application Form

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

Select Country

Phone Number

Alternate Phone Number

Email Address

Emergency Contact Details :

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

Clinical Volunteer Application Form

Clinical Volunteer Application Form

Emergency Contact Details :

License Information :

Address

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