Clinical Quality Management Committee Volunteer Application

Please read this carefully before proceeding.

The MOL Clinical Quality Management Committee volunteer roles are for persons living with HIV/AIDS (PLWH). Volunteers must be comfortable discussing their diagnosis publicly. Volunteers must be a current client of MOL receiving Ryan White HIV/AIDS Program or Ending the HIV Epidemic (EHE) services.

If you are not willing to disclose your HIV status publicly, please do not complete this application.

Name

First

Last

Are you at least 18 years of age?

Are you HIV positive?

Yes
No

Email

Confirm Email

Phone (Mobile)

Phone (Home)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact

Name

First

Last

Relationship

Phone

Education

Please list any special certifications or training you have had

Highest Level of Education Completed

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Have you ever been convicted (found guilty) of a crime, or do you have any pending criminal charges awaiting hearing?

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Previous Volunteer Agency

Start Date

Position

Previous Volunteer Agency

Position

Are you required to volunteer?

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What attracted you to this volunteer program? Is there an aspect within the program that motivates you to be a part of this program?

What would you like to get out of your volunteer experience/internship? What would make you feel like you have been successful?

Describe your ideal supervisor. What sort of supervisory style do you prefer to work?

What skills and qualities do you feel you have to contribute to the Clinical Quality Management Committee?

Are you willing to commit to the requirements of the Clinical Quality Management Committee?

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I certify all information is true and has been given voluntarily. I understand that this information may be disclosed to any party with legal and proper interest. I release the agency from any liability whatsoever for supplying such information.

I certify

I understand that I must be 18 years of age to volunteer for the Miracle of Love Clinical Quality Management Committee. I must be HIV positive, and willing to discuss my diagnosis publicly. I understand that I must be receiving services through the Ryan White HIV/AIDS Program, the Ending the HIV Epidemic (EHE) program, or long-term housing services.

I understand