HOMES Signup time request form for Medical Students

Thank you for your interest in HOMES! We are tremendously appreciative of all the efforts of our volunteers, as are the patients that we have served.

Pharmacy Students and School of Public Health Students accompany up to 4 Clinical and 8 Basic Science Medical Students on our patient care teams Sunday. 4 Teams are assembled (maximum of 4 students per team). Managers must have completed our manager's training program.

There may be a lag time between when you post your request and when the schedule can be updated. It is possible that the date you request will already be taken by another HOMES volunteer. Signup is done on a first-email first serve basis.

E-mail address:	(Complete address, e.g. "jdoe@yourschool.edu")
First Name:
Last Name:
School:
Phone:	(optional)
Pager:	(optional)
Committee:	(if applicable)
Are you receiving course credit for working at HOMES?: (If ‘YES’, please include no. of visits remaining below)		Yes
Classification (year):	MS1 MS2 MS3 MS4 SPH Pharm Other
Position requested:	Clinical Student Basic Science Student Manager Manager Trainee SPH Team Member Pharmacy Student PDD Survey Other
Are you willing to be additionally considered as an alternate?:		Alternate
If you answered yes, may we contact you by telephone?:		Permission to contact by phone
Requested dates (mm/dd/yy):
Please submit any questions/comments you may have, especially if you answered "other" on any items.

The policy of HOMES Student-run clinic is to schedule students to volunteer at the clinic over an approximately two month span. Students may sign-up for as many or as few Sundays as they want. The schedules for students are either posted on the website (www.homeless-healthcare.org under student clinics and then under schedules) (for medical students and public health) or are scheduled by the school's coordinator (pharmacy). If a student is unable to attend the Sunday(s) scheduled, then it is the responsibility of the student to find a replacement the Thursday before and/or notify the HOMES representatives in charge of scheduling by this deadline. Students who do not find replacements or notify representatives within a timely manner may have their rights to participate at the clinic in the future suspended.
Students should arrive at the church by 8:00 am at the latest.
I have read the above policy and understand and accept the requirements and duties of participating in this program.
Select to submit your request. Thank you very much!
Select to erase everything in the form.

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