Dear Prospective Volunteer:


Thank you for your interest in volunteering to serve in the Beauregard Agape Community Clinic. Volunteer

service makes possible the provision of quality health care to some who would otherwise not be able to receive the

care they need. Service here carries with it important responsibilities and some restrictions which are unique to

working in a health care facility. The most important of these relates to the confidentiality of the facility-patient

relationship and the information concerning patients. This confidentiality is protected by Federal law and by State

laws. You will be required to sign your pledge to obey the policies of the clinic concerning this and other matters

such as dress and behavior after they have been explained to you in an orientation session.


The Clinic is a non-profit corporation chartered under the laws of the State of Louisiana. It is governed by a Board

of Trustees comprised of local men and women with specific skills and an interest in the mission of the Clinic who

volunteer their time and expertise to help make the Clinic successful.


Our mission is to help many in our community who work but lack health insurance and adequate resources to

provide for their health care needs, including medication. We appreciate your willingness to support this work

with your own particular skills and personality. All who serve here are volunteers, and with your help, we can

make a difference.


Please provide the information requested below. When your application is approved, you will be contacted for the

orientation session. If you are not contacted in a reasonable time, please feel free to check back with us. Thanks.




First Name:         Last Name:        


Middle:                   Preferred:        

Date of Birth - Month:           Day:         Year:    


Street Address:  




Phone - Home:        Work:       





Have you ever been convicted of or pled no contest to the charge of a felony?   If yes, give details.


   Yes (If Yes, enter explanation below)





AREA OF PREFERENCE FOR SERVICE - Check as many as you would like


Professional (licensed) - We will need a copy of your professional diploma and current year's license


Physician    Nurse (NP, RN, LPN)    Nursing assistant    Lab tech   

Optometrist    Dentist    Pharmacist    Pharmacy tech    Psychologist   

Social Services    Nutritionist    Other Prof:


Other areas of service


Chaplain    Interviewer/screener    Computer tech    Data entry   

Newsletter/publicity Receptionist/greeter     Special events    Translator/interpreter

Housekeeping/building maintenance    Food for volunteers    Other: