Medical Providers Volunteer Requirements
Medical Provider Volunteers
Professional Medical Volunteer Providers must obtain and submit the following forms:
- Review the CFPB Summary of Rights document. Sign the Acknowledgement and Authorization for Background Checks. Provide to the Leahy Community Health and Family Center. You must understand your rights prior to submitting for Federal and State Clearances.
- Volunteer Provider Initial Application
- Statement of Fitness/Medical Clearance PPD
- Pennsylvania Request for Criminal Record Check (PDF) or Pennsylvania Criminal Record Check (Online Application)
- Pennsylvania Child Abuse History Clearance Form Instructions for how to complete this clearance can be found on page three of the PDF.
- Instructions & service code to complete the FBI Finger Print Background Check (Online Application)
- Volunteer License Application -- PA Code 16.18. Volunteer license
Nursing/Pharmacy/Other Healthcare Providers
- Volunteer Nursing/Pharmacy/Other Initial Application
- Statement of Fitness/Medical Clearance PPD
- Pennsylvania Request for Criminal Record Check (PDF) or Pennsylvania Criminal Record Check (Online Application)
- Pennsylvania Child Abuse History Clearance Form Instructions for how to complete this clearance can be found on page three of the PDF.
- Instructions & service code to complete the FBI Finger Print Background Check (Online Application)
- Volunteer License Application -- PA Code 21.602. Volunteer license
Physical Therapy Volunteer Providers
Physical therapy providers interested in volunteering must obtain and submit:
- Pennsylvania Request for Criminal Record Check (PDF) or Pennsylvania Criminal Record Check (Online Application)
- Pennsylvania Child Abuse History Clearance Form Instructions for how to complete this clearance can be found on page three of the PDF.
- Physical Therapy Provider Initial Application