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Rural Parish Clinic - Medical and Dental//Volunteers

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Volunteer Driven

The Rural Parish Clinic - Medical and Dental are both volunteer-driven... literally! We need volunteers with different skill sets and interests: drivers, donors, doctors, nurses, dentists, hygienists, and people to welcome clients.

LEARN MORE ABOUT SPIRITUAL APOSTOLATE OF THE RURAL PARISH CLINIC

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Volunteer sign-up
We are grateful you have chosen to volunteer with the Rural Parish Clinic of the Archdiocese of St. Louis (RPC). We welcome you to participate with us in the healing ministry of Jesus Christ. Please complete the following application in full.
Please note your information is private and will not be shared outside of this organization.
1. PERSONAL DATA
Applicant Name:

Last Name
First Name
Middle Initial
Have you ever used any other names in the past?
Yes
No
If yes, list other names here:

Applicant Address:

Street Address
Street Address 2
City	State / Province
Postal / ZipCode	Country

Applicant Phone:
Area Code - Phone Number
Applicant Email:
Applicant Birthdate:
Month - Day - Year
What date would you be available for volunteering?
Month - Day - Year
What tasks would you most enjoy and prefer? I would like to volunteer as a....
Doctor
Nurse
Dentist
Hygienist
Dental Assistant
Receptionist
Driver
Administrative work in the office
Special projects
Prep and cleaning of the clinic
Scanning documents into the electronic medical record
Public relations support for events throughout the year
Development
Case management
Other (please specify)
Other volunteer preference:
Have you ever been discharged or requested to resign from any position?
Yes
No
If yes to been discharged or requested to resign, please explain:
Have you ever been convicted of/pleaded guilty to a misdemeanor/felony?
Yes
No
If yes, please state the nature of the offense for which you were convicted or pleaded guilty, date of conviction or entering of plea, judgment imposed, the court imposing judgment and its location, and docket number of proceeding:
A yes response to either of the two preceding questions will not disqualify you from consideration. A record of conviction, or a refusal by a surety company to issue or continue a bond on your behalf, does not mean that you cannot volunteer. The nature and circumstances of any conviction or bond refusal, how long ago either occurred, or other factors, including the relationship of the conviction or bond refusal to the position for which you are seeking to volunteer, are all important in the volunteerism consideration. Thus, please provide a complete response to these questions so that an appropriate decision can be made. In connection with your application to volunteer and at any time during your volunteering, if selected, you may be required to submit to the Rural Parish Clinic of the Archdiocese of St. Louis a copy of any and all records regarding your convictions that have been maintained by either the police or sheriff departments. If you have not been convicted of or pleaded guilty to a misdemeanor or a felony, you may be required to submit written confirmation of that signed by an authorized official of the police and sheriff departments listed above.
If the following section does not apply, please mark each question ‘N/A’ and proceed to section 2.
Have you at any time been accused of child abuse?
Yes
No
(You are required to answer this inquiry whether or not a criminal conviction arose out of the allegation.)

If yes, complete the following:

Provide in detail the date, place, and an account of the circumstances surrounding each allegation of abuse:
Date of Alleged Abuse:
Month - Day - Year

Address of Alleged Abuse:

Street Address
Street Address 2
City	State / Province
Postal / ZipCode	Country

Circumstances of Alleged Abuse:
Did any administrative or judicial proceedings arise out of the allegations?
Yes
No
If yes, please identify the agency or court in which the proceeding was brought and its location, the parties to that proceeding, the docket number of the proceeding, and any judgment or resolution that was entered or reached:
Are you under the supervision of any federal, state, or local agency as a result of any allegations of child abuse?
Yes
No
A yes response to any of the three preceding questions will not necessarily disqualify you from consideration for employment. The nature and circumstances of the matters reported as well as their disposition are all important factors in consideration.
2. EMPLOYMENT OR VOLUNTEER EXPERIENCE
Are you currently employed?
Yes
No
Are you currently volunteering?
Yes
No
Name of most recent employer or volunteer organization:
Positition Held:
Supervisor Name:
Supervisor Phone:
Area Code - Phone Number
Supervisor Email:
Describe primary duties, particularly those you most enjoyed:
3. SKILLS AND AFFILIATIONS
Describe any training or apprenticeships, professional or social affiliations, or any specialized skills that you possess that may be pertinent and valuable to the RPC:
4. EDUCATION
Undergraduate University:
Undergraduate Graduation Date:
Month - Day - Year
Graduate School University:
Graduate School Graduation Date:
Month - Day - Year
5. EMERGENCY CONTACTS
The family member/friend contact information provided below will be used in the event of a medical emergency for a volunteer.
First Emergency Contact Name:

First Name
Last Name
Relationship
First Emergency Contact Phone:
Area Code - Phone Number
Second Emergency Contact Name:

First Name
Last Name
Relationship
Second Emergency Contact Phone:
Area Code - Phone Number
6. SIGNATURE
I attest by signature below that all portions of this application have been completed thoroughly and accurately to the best of my knowledge. I grant permission to the Rural Parish Clinic (RPC) to verify all information.
Signature:

First Name
Last Name
Signature Date:
Month - Day - Year
7. SAFE ENVIRONMENT CERTIFICATION
All volunteers and employees of the Archdiocese of St. Louis are required to complete Safe Environment trainings within the Prevent and Protect program. Two trainings, Code of Conduct and Mandated Reporter, are online, available 24/7, to be completed at your convenience. The final training, Protecting God’s Children (PGC), must be completed as a live class, either via Zoom or as an in-person training offered at a parish site or other location. Registration information for these trainings and upcoming classes can be found at:

https://www.archstl.org/Portals/0/Documents/Child_Youth_Protection/PreventAndProtectSTL-Registration.pdf?ver=2019-12-03-170557-267
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Volunteer Driven

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Volunteer sign-up

1. PERSONAL DATA

2. EMPLOYMENT OR VOLUNTEER EXPERIENCE

3. SKILLS AND AFFILIATIONS

4. EDUCATION

5. EMERGENCY CONTACTS

6. SIGNATURE

7. SAFE ENVIRONMENT CERTIFICATION

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