WFM Volunteer Credentialing Form

WFM Volunteer Credentialing Form

Name [First Last]*

Email*

Phone Number*

Why do you want to volunteer with WFM?

Date of Negative TB*

A negative TB less than a year old is required

Background Check*

https://business2.backgroundchecks.com/invitation/welcome/YgWM

Please copy the link above to fill out your background check.

Fully Vaccinated*

Select or enter value

HIPAA/Child Abuse

Date of Expiration

HIPAA/Child Abuse training are annual requirements, please add your expiration date below.

Start Date

Your ideal start date

End Date

Desired Assignment Location

Bellmead Community Clinic

Bell's Hill Community Clinic

Community Clinic at MCC

Community Clinic at Santa Fe

Elm Avenue Community Clinic

MacArthur Pediatric Clinic

Madison Cooper Community Clinic

Martin Luther King Community Clinic

McGregor Community Clinic

Meyer Center Community Clinic

South 18th. Street Community Clinic

Waco Family Medicine Central

West Waco Community Clinic

Women's Health Center

Waco Family Medicine- Pharmacy

Waco Family Medicine- Wellness Center

Are you fluent in a language other than English?

Emergency Contact

Emergency Contact Phone

Additional Information

File Upload

Upload all supporting documents here [Negative TB, Driver's License Photo, Covid-19 Waiver, Immunization Record, Background Check REPORT and Vaccination Record]

Click the link below to access HIPAA and Child Abuse requirements and the Covid-19 Waiver: https://drive.google.com/drive/folders/1Z9ITunfZ1tCexul3lDDo6MUn7PEDimJd?usp=sharing

Drag and drop files here or

Send me a copy of my responses

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