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

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Are you at least 18 years of age? *

Are you HIV positive? *

Yes
No

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Email *

Email

Confirm Email

Phone (Mobile) *

Phone (Home)

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact

Name *

First

Last

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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

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Previous Volunteer Agency

Position

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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