Cabrini Clinic of Most Holy Trinity Church
1050 Porter Street
Detroit, MI 48226-2405
(313) 961-7863 Fax (313) 965-9891

Volunteer Application Form

Date:_________________________________ Name: _______________________________________________________

Home Address: ______________________________________________________________________________________

__________________________________________________________________________________________________

Home Phone: (____)_______________ Work Phone: (____)_______________
Cell Phone: (____)_______________
eMail Address:_________________________

Current Employer: ____________________________________________________________________________________

Job Title: ___________________________________________________________________________________________

Area of Specialty/Credentials: ____________________________________________________________________________

Capacity in Which You Would Like To Volunteer: ______________________________________________________________

__________________________________________________________________________________________________

I am available to volunteer for the following shifts:

5 to 8 p.m. on the __1st __2nd __3rd __4th Tuesday evening of the month.

1 to 5:30 p.m. on the __1st __2nd __3rd __4th Thursday afternoon of the month.

5 to 8 p.m. on the__1st __2nd __3rd __4th Thursday evening of the month.

I would like to begin volunteering in the month of ____________________________

Other relevant information: ____________________________________________________________

___________________________________________________________________________________.

Please attach a copy of:
Your current professional license
DEA Number
Professional Liability Insurance Coverage (if applicable)
Your resume