Volunteer

Volunteer Application
Our Mission:

As a witness for Jesus Christ, Medical Outreach Ministries exists to minister to the physical, emotional, and spiritual needs of the medically underserved by providing free healthcare services.

Thank you for your interest in volunteering at MOM.

Please supply the following information.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

PrefixFirst NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Highest Education obtained/Degree received:
Professional License Type:
License Active?
Have you ever been convicted of a crime except for minor traffic violations?
If Yes, Please Explain:
Please list 2 of your personality traits:
Hobbies you enjoy:
What languages do you speak?
Would you be willing to serve as an interpreter?
Work/Volunteer Experience (Please include specific skills/tasks):
Do you have reliable transportation?
If No, please explain:
If God has called you to be a part of this ministry in any way, your only requirement is to follow Jesus and love every person who walks through the doors of Medical Outreach Ministries.
We are excited you are interested in sharing your gifts at MOM!

Volunteer Health Questionnaire
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Last 4 digits of Social Security #:
In Case of Emergency Contact:

First NameLast Name
Relationship:
Home Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Medical Outreach Ministries invites you to list below any medical conditions about which you would like for us to be aware, even though these conditions do not impair your ability to perform as a volunteer in the Clinic. We also invite you to list any medications that you are currently taking and the name of your primary physician.

This information would be used only if you require health assistance or on an urgent or emergency basis while volunteering at MOM. You are not required to provide us with this information; however, any information you do provide will be treated with strict confidentiality. However, we do require that you inform us of physical limitations and any past allergic reactions to insect stings, foods, or medications.
Physical Limitations:
Medication, insect, or food allergy:
Type of reaction:
Medical Conditions:

Medication List:

Rows	Name of Medication	Strength of Medication	How Often is Medication Taken
1
2
3
4
5
6
7
8

I attest that I am currently free of any physical or mental conditions that would impair my ability to perform the functions I agree to as a volunteer of MOM. I also attest that currently I am free of addiction to drugs, alcohol, or any other recreational chemical substances. I understand that I may not hold Medical Outreach Ministries responsible for any conditions that I have or have not disclosed.
Signature of Volunteer
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Medical Outreach Ministries Guiding Principles
- In the name of Jesus Christ, MOM seeks to meet the physical, emotional, and spiritual needs of individuals who access healthcare at MOM.
- MOM never discriminates in ministering to anyone receiving care at MOM regardless of race, religion, creed, color, national origin, marital status, sex, or disability.
- MOM does not assess any fees for services, medications, or medical supplies rendered.
- MOM is committed to professional excellence as we do our work “heartily as unto the Lord, not unto men.” (Colossians 3:23).
- MOM volunteers are committed to protecting patient confidentiality.
- MOM is committed to demonstrating the love and compassion of Jesus Christ through our words, actions, and demeanor to MOM patients and to one another. These are just some of the Bible verses that guide our mission:
  - In the Words of Jesus: “…I was a stranger and you invited me in….I was sick and you looked after me….For truly I tell you, whatever you did for one of the least of these brothers and sisters of mine, you did for me. ” (From Matthew 25:35,40)
  - “Be ye kind one to another, tender-hearted, forgiving one another even as God, for Christ sake has forgiven you.” Ephesians 4:32
  - “From Him the whole body, joined and held together by every supporting ligament, grows and builds itself up in love, as each part does his work.” Ephesians 4:16
  - “Be completely humble and gentle; be patient, bearing with one another in love. Make every effort to keep the unity of the Spirit through the bond of peace.” Ephesians 4:2-3.
  - [Lord], You have been a refuge for the poor, a refuge for the needy in their distress, a shelter from the storm and a shade from the heat.” Isaiah 25:4.
  - “She opens her arms to the poor and extends her hands to the needy.” Proverbs 31:20
Initial Here:

Medical Outreach Ministries Volunteer Agreement
1. I will be punctual and conscientious, conduct myself with dignity, courtesy, and consideration of patients, staff, and volunteers, and endeavor to exhibit professional excellence in my work.
2. I will hold in strict confidentiality all information that I may obtain concerning patients, volunteers, and staff. I will not seek to obtain confidential information from patients unless it is part of my work assignment. I will not seek to obtain my personal health information via MOM’s computers or network.
3. I will attempt to resolve any volunteer challenges or conflicts with others in a Christ-like manner. If I need help, I will seek help from the MOM Executive Director.
4. I agree to dress in a modest business casual manner or in professional attire.
5. I will only use my first name and identify my association with MOM when leaving phone messages for patients.
6. I understand that I may be terminated at any time if my behavior is deemed inappropriate. Examples of inappropriate behavior may include breach of confidentiality, sexual harassment, use of or effects from alcohol or drugs while working at the Clinic, theft or misuse of Clinic property, unsatisfactory attitude, appearance, repeat absences without notification, and/or use of inappropriate language.
7. I will make my best effort to fulfill any assignment I accept with excellence, “as unto the Lord.”
8. I will at all times strive to uphold the Christian standards and mission of Medical Outreach Ministries while at the clinic and otherwise.
I have read and understand each of the above conditions and agree to uphold them.
Signature of Volunteer:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Rows	8am - 12:30pm	10am - 2pm	12pm - 4:30pm
Monday
Tuesday
Wednesday
Thursday
Friday

Volunteer Application

Volunteer Health Questionnaire

Medical Outreach Ministries Guiding Principles

Medical Outreach Ministries Volunteer Agreement