Coweta Samaritan Clinic Volunteer Application Logo
  • Coweta Samaritan Clinic Volunteer Application

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  • *Physicians must possess a valid medical license in any jurisdiction in the US as required for his/her discipline or specialty.

    ** Nurse Practitioners and certain other licensed health care professionals must possess a valid license in the State of Georgia as required for his/her specialty or discipline.

    ***RN/LPN, and others, in certain circumstances, may participate with expired licenses

  • Previous Volunteer Experience

  • Employment History

  • Education

  • References

    Please do not list relatives. All information must be completed in full.

  • Volunteer Service Availability

    Please check all that apply

  • Applicant’s Certification and Agreement

    Please read carefully


    I understand that if I am selected to be a Volunteer, it will be my responsibility to:

    • Attend an orientation program scheduled for new members and attend service area training in my specific service area

    • Complete annual re-orientation requirements

    • Fulfill my assignments and hour obligations because the Clinic staff and patients depend on me

    • Find a replacement if I am unable to work my normally scheduled hours and if unable to find a replacement, contact my volunteer service area coordinator

    • To remember that “free care” in no way implies second class medicine. Patients are treated with the utmost courtesy and respect and receive the highest quality patient care possible.

    • To respect the confidential nature of our work

    • To be sensitive to our patients and to not have personal conversations in their presence

    • To accept an assignment with only as much responsibility as I can handle

    • To be punctual when reporting for my assigned shift and to give the Nurse Administrator as much notice as possible if I am unable to keep your commitment

    • To use good judgment in terms of my own physical condition and not attend the clinic with any communicable illness or with any condition that could negatively impact my ability to work effectively or deliver quality patient care

    • To follow dress code guidelines

    • To discuss any patient requests (e.g.asking for a ride or money) with the Nurse Administrator and to not commit to any such services)

    • To refuse gifts or tips, except when a patient makes or offers something of nominal value as a way of saying “thank you”

    • To provide feedback, suggestions and recommendations to the clinic staff

    • To be considerate, respect competencies, and work as a member of the team with staff and volunteers

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