JOIN THE MAVEN PROJECT Whether you’re a veteran physician or a community health center: there are multiple ways to take part in The MAVEN Project. COMMUNITY CLINIC VOLUNTEER SUPPORTER Clinic Inquiry Form What is the full legal name of your organization? Primary Contact: First Name Last Name Primary Contact Email Primary Contact Job Title Please tell us a little more about your organization, including other area(s) of need: In which state is your organization located?Please select... AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Please provide your organization's website: How did you initially hear about us?Please select... Referral Online Search Professional Organization Television Social Media Event (Webinar/Conference) Other If "Other", please tell us more: Contact Information We welcome physicians from primary care and medical specialties to volunteer a minimum of 4 hours per month for at least 6 months - to provide clinical advice, mentorship, and education to primary care providers in community health centers. Sal.Please select... Dr. Mr. Mrs. Ms. First Name Last Name Email Mobile Phone Number What best describes the area of medicine in which you are trained? If you are trained in multiple specialties, please click “Add another area of medicine” on the righthand side of the page. If your specialty is not listed, please select “Other” in the dropdown menu.Please select... Addiction Medicine Allergy & Immunology Allergy & Immunology, Pediatric Behavioral Medicine Cardiology Cardiology, Pediatric Dermatology Endocrinology Endocrinology, Pediatric Endocrinology, Transgender (Adult) Endocrinology, Transgender (Pediatric) Gastroenterology Gastroenterology, Pediatric Genetics Geriatrics Gynecology Hematology Hematology, Pediatric Hepatology HIV/AIDS Infectious Disease Infectious Disease, Pediatric Lipidology Nephrology Neurology Neurology, Pediatric Neuro-Oncology Oncology Oncology, Pediatric Ophthalmology Orthopedics/Sports Medicine Orthopedics/Sports Medicine, Pediatric Otolaryngology Pain Management Palliative Care Psychiatry Psychiatry, Geriatric Pulmonary Disease Rheumatology Sleep Medicine STD/STI Urology Urology, Pediatric Vascular Surgery Wound Care Other Please describe the other area(s) of medicine in which you are trained: Please mark all states in which you hold an active medical license, including volunteer medical licenses: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY No Active License Upload CV Please include a copy of your most current CV to help us learn a little more about you. Are you currently active in clinical practice?YesNo Briefly describe your clinical practice. When were you last active in clinical practice? Briefly describe your clinical practice. What has your involvement in medicine been since retiring? Do you currently volunteer in a medical setting? Briefly describe this work. Do you feel comfortable advising clinic providers about medication management? (This does not include the actual prescribing of drugs.) Please describe your current work status.Please select... Full time Part time Retired Please enter the month & year of your retirement. Please share any comments or questions. How did you initially hear about us?Please select... Alumni Association Brochure Conference Event Individual Referral Newspaper Online Search Professional Organization Facebook Google LinkedIn Twitter Television VolunteerMatch Zoom Blog Unknown Please provide the name of the person who referred you to the MAVEN Project: First Name Last Name Yes, I would like to receive MAVEN Project news Contact Information
