Volunteer With Us - Rural Parish Clinic

Thank you for your response. ✨

Share Your Time. Share Hope.

Whether you are a medical professional, an administrator, or simply someone with a generous heart and willing hands, there is a place for you at the Rural Parish Clinic. Our volunteers are the backbone of our mission to bring free, compassionate care to uninsured adults across rural Missouri.

To ensure the safety of our patients and the integrity of our mission, all applicants undergo a thorough vetting process, including a background check and completion of the Archdiocese of St. Louis Safe Environment training. We appreciate your patience and understanding as we work to maintain the highest standard of care for those we serve.

Name

Have you used any other names in the past?

Name

Birth Date (YYYY-MM-DD)

Applicant’s Address Line 1

Applicant’s Address Line 2

City

Select State

Zip Code

Applicant’s Phone Number

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

The family member/friend contact information provided will be used in the event of a medical emergency for a volunteer

Applicant’s Available Start Date (YYYY-MM-DD)

What tasks would you most enjoy or prefer? I would like to volunteer as…

Other Volunteer Preference

Have you ever been discharged or requested to resign from a position?

If Yes, please explain

Have you ever been convicted of/pleaded guilty to a misdemeanor/felony?

If Yes, please explain

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 or leave blank and proceed.

Have you at any time been accused of Child Abuse?

If Yes, Please complete the following: You are required to answer this inquiry whether or not a criminal conviction arose out of the allegation.

Approximate Date of Allegation (YYYY-MM-DD)

Place Allegation Occurred:

Provide in detail the date, place, and an account of the circumstances surrounding each allegation of abuse

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

Address of Alleged Abuse Line 1

Address Line 2

City

Zip Code

Are you under the supervision of any federal, state, or local agency as a result of any allegations of child abuse?

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.

Are you currently employed?

Are you currently volunteering?

Name of most recent employer or volunteer organization

Position Held

Supervisor’s Name

Supervisor’s Phone Number

Describe any training or apprenticeships, professional or social affiliations, or any specialized skills that you possess that may be pertinent and valuable to the Rural Parish Clinic:

Undergraduate University Name

Undergraduate Graduation Date (YYYY-MM-DD)

Graduate University Name

Graduate Degree / Field of Study

Graduate School Graduation Date (YYYY-MM-DD)

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: www.preventandprotectstl.org

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.

I agree to complete Safe Environment Training: Signature

Today’s Date (YYYY-MM-DD)