MCAC Volunteer Application

Medical Care Access Coalition, Inc.
1414 West Fair Ave. Suite 26 Marquette, Michigan 49855
Phone 906.226.4400 Fax 906.226.4407

Volunteer Application

Position you are applying for (Circle) : Enrollment Councilor, Clerical, Rx

PERSONAL INFORMATION
NAME ______________________________________________________________________
ADDRESS ___________________________________________________________________
CITY ________________________________________ STATE ________ ZIP ____________
PHONE H ________________________ W _______________________ FAX_____________
E-MAIL _____________________________________________________________________
SOCIAL SECURITY NUMBER_____________-__________-_______________
DRIVERS LICENSE NUMBER___________________________________________________
CURRENT PLACE OF EMPLOYMENT____________________________________________
PROFESSION __________________________ Can you be reached at work? YES____NO ____
EMERGENCY CONTACT NAME _________________________ PH ____________________


Where did you hear about MCAC and our volunteer opportunities?

Have you been convicted of a felony within the past five years? YES _____ NO _____
If YES, briefly explain: ____________________________________________________________

If you have a disability, what accommodations would you need to volunteer for this position?

EDUCATION AND WORK EXPERIENCE
Level of education: ________________________ Field of study __________________________
Are you currently a student? YES _______ NO ________
Do you hold a professional license(s)? YES_____ NO _____
If so, what license(s)? ____________________________ License(s) Number__________________

Please list any current or previous work or volunteer experience.

Company______________________________________Supervisior________________________
Address_______________________________________________________________________
Phone_______________________________________________Job Title___________________
Duties_________________________________________________________________________
Dates Served ___________________Reason for Leaving_________________________________

Company______________________________________Supervisior________________________
Address_______________________________________________________________________
Phone________________________________________________Job Title__________________
Duties_________________________________________________________________________
Dates Served ___________________Reason for Leaving_________________________________

Company______________________________________Supervisior_______________________
Address_______________________________________________________________________
Phone__________________________________________Job Title________________________
Duties________________________________________________________________________
Dates Served ________________Reason for Leaving___________________________________

AVAILABILITY

When are you available to volunteer?

Time of Day
Day(s) of Week
How often per month?

How long do you anticipate being available to volunteer?

What attracted you to MCAC in particular?

What skills, training or knowledge do you wish to utilize at MCAC?

What training, resources or support do you anticipate needing to do this volunteer work?
REFERENCES

Please provide three personal or professional references:

Name Phone Number Relationship

1.____________________________________________________________________________

2.____________________________________________________________________________

3.____________________________________________________________________________

APPLICANT CERTIFICATION AND AGREEMENT

I hereby certify that the facts set forth in this application are true and complete to the best of
my knowledge. I understand that discovery or falsification of any statement or significant omission
of fact may prevent me from obtaining a volunteer position or may subject me to immediate
dismissal from that position. I authorize Medical Care Access Coalition to verify all data given
in my application and oral interview.

______________________________________________
Signature and Date