Please check all that apply to you:

Full Name:

E-mail Address:

Home Address:

Home Phone:

Cell Phone:

Work Phone

Emergency Contact (include #):

Volunteer Position:

WV Professional Lisence #:

GSFC Statement of Faith

The following statements are a summary of the beliefs which the Good Samaritan Free Clinic(GSFC) believe to be essential to the practice and propagation of true biblical Christianity, and therefore are held by the GSFC:

1. The Bible is the inspired, only infallible, authoritative Word of God.
2. There is one God, eternally existent in the three persons: Father, Son and Holy Spirit.
3. Jesus Christ of Nazareth is God the Son, born on earth of a virgin, lived a sinless life, performed miracles, suffered a vicarious and atoning death through His shed blood by crucifixion, bodily resurrected from the dead, bodily ascended into Heaven to sit at the right hand of God the Father, and will personally and bodily return to earth in power and glory.
4. Spiritual regeneration by God the Holy Spirit is absolutely essential for the salvation of lost and sinful man, and this salvation can only be received through personal faith and confession of Jesus Christ as Savior and Lord and not as a result of good works.
5. God the Holy Spirit indwells every true believer in Jesus Christ, enabling him to live a godly life and perform good works.
6. There will be a resurrection of the saved (those who have received Jesus Christ) and the lost ( those who have rejected Jesus Christ): the saved to a resurrection of eternal life and the lost to a resurrection of eternal damnation.
7. All true believers are united by God the Holy Spirit in our Lord Jesus Christ.

I profess that the above is true, and agree with the mission of the Good Samaritan Free Clinic.

STATEMENT OF CONFIDENTIALITY

Good Samaritan Free Clinic staff and volunteers are responsible for protecting the privacy of Good Samaritan clientele. No information about clientele is to be given verbally or written to agencies, and no pictures are to be taken without a signed release form of information from the specific individual involved.

Initials:
Date: