Volunteer Registration

St. Mark Coptic Orthodox Church | Coptic Medical Clinic

Registration: Free Clinic Volunteers (05-19-2012 - 05-25-2013) PLEASE READ THE FOLLOWING CAREFULLY BEFORE REGISTRATION: The St. Mark clinic is a free medical clinic for patients who can’t afford healthcare or are uninsured. The clinic will be held at 1600 S. Robertson Blvd, Los Angeles CA 90065, on the third Saturday of every month. Volunteers are expected to take the morning shift (8 am to 12 pm), the afternoon shift (1 pm to 5 pm), or the whole day. It is imperative that volunteers arrive on time and stay for the whole shift. This registration form is for all volunteers (physicians, social workers, etc.), to collect basic information to help us organize the clinic activities. *** Health professionals MUST have a valid California license. After you register, please provide up-to-date copies of your California license (health professional), your DEA, NPI, and insurance information to the Clinic Directors (Christine Salib 818-632-3090 or John Eid 310-924-0997) prior to your first day of volunteering. *** Please also contact your malpractice insurance and inform them of your participation in this program. *** Minimum age to volunteer is 16 *** Disclaimer: You are responsible for your own malpractice insurance.
* Required

Section I | Personal Information











Section II | Volunteer Information









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Contact Us

Physical Address:
1600 South Robertson Blvd.
Los Angeles, CA 90035

Mailing Address:
PO Box 351388
Los Angeles, CA 90035

Phone: (310) 275-3050
Fax: (310) 276-6333
support[at]stmarkla.org