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Online Volunteer Application
 
Position you're applying for:
 
Name: Address:
City: State: Zip:
Employer: Profession:
Phone: (H) (W) (C)
Email: Date of Birth:
Emergency Contact Name:
Emergency Contact Phone:
Where did you hear about Community Healthcare Center and our volunteer opportunities? 
Have you ever been convicted of a felony within the past five years?  Yes   No

If YES, please explain (conviction will not necessarily disqualify candidates):
If you have a disability, what accommodations would you need to perform this position?
When are you available to volunteer?
Time(s) of Day:
Days of Week:
Frequency (per month):
What attracted you to Community Healthcare Center in particular?
What skills, training or knowledge do you wish to utilize at Community Healthcare Center?

Describe a personal or work situation when you felt or would feel successful.

Please provide two personal or professional references:
  Name Number Relationship
1.
2.
By submitting this form I hereby attest that the above information is true to the best of my knowledge.  I give permission to Community Healthcare Center to perform a civil and criminal background check to further evaluate my candidacy for enrollment in its volunteer program.
 
Return to Volunteer Application and Enrollment
  Community Healthcare Center
  200 Martin Luther King Jr. Blvd.
  Wichita Falls, Texas
  76301
 
  CHC - Juarez Medical Clinic
  1000A Juarez St.
  Wichita Falls, Texas
  76301
 
  Medical: (940) 766-6306
  Dental: (940) 322-4297
 
  Mailing Address:
  P.O. Box 720
  Wichita Fall, Texas
  76307-0720
 
  Corporate Fax: (940) 761-1698
  Records Fax: (940) 766-6504
 
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