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Registration: Kind Clinic

If you have already registered for access to our online scheduling system and you have already received your welcome email message with your temporary password, please sign in using that password.

If you have not completed this form, thank you for taking a moment to complete and submit the following details.

Thank you for your patience, it might take a few hours or days until your registration has been processed.

* required field

* First Name

* Last Name

* Email

Address

City

State/Province

* Zip/Postal Code

* Primary/Home Phone

Other/Work Phone

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Relationship

What is your date of birth?

How did you hear about volunteer opportunities at the Kind Clinic?

If a staff member or volunteer referred you, who was it?

Most people want to volunteer to give back to their community. What are your reasons for wanting to volunteer at the Kind Clinic?

By checking this box you certify that all responses to this form are true to the best of your knowledge. You also agree that all information may be verified by the Texas Health Action.

Yes

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We appreciate your time and interest

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