Clinical Volunteer Application – GLOBAL HEALTH AND EDUCATION, INC

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 *

Street Address *

City *

State *

ZIP / Postal Code *

Country *

Phone Number: *Primary Phone Number

Alternate Phone NumberSecondary Phone Number

Email Address *

Emergency Contact:- 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:

DEA Number:

Expiration Date:

NPI Number: