To Volunteer Applicant: We appreciate your interest in volunteering for our organization and assure you that your qualifications will be seriously considered. A clear understanding of your background and interests will aid us in placing you in the volunteer position that best meets your experience. The use of this form does not in any way obligate Texas Health Presbyterian Hospital Rockwall (“PHR”). This Volunteer Application will be kept on file at least 90 days from the date of application. |
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How You Heard About Our Program |
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Have You Ever Served As A Volunteer At PHR Before? | |
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| Have you ever been convicted of, been given probation or deferred adjudication in lieu of sentencing, or plead no contest for any offense, including misdemeanors, other than for minor traffic violations or are you charged with an unresolved criminal charge? (Are you charged with a crime that has not yet resulted in a plea of guilty, court trial, deferred adjudication or dropping the charge?) | |
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If Yes, Explain: |
| Note: A “yes” answer to these questions does not automatically disqualify you for Volunteer Services. The nature and date of the crime/charge and type of volunteer service for which you are applying will be considered. However, falsification of this application will be sufficient cause for rejection of volunteer application or immediate dismissal of services. |
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Do You Have Any Relatives Who Work For Or Have Worked For PHR? | |
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| Personal and/or Employment References (no relatives) |
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| Reference 1 Address |
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| Reference 2 Address |
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Previous Work Or Volunteer Experience |
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Are You Bilingual? | |
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Special Education, Training, Skills (Including Computer) & Interests |
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Reason For Volunteering |
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What Will Make Your Volunteer Experience A Success? What Do You Hope To Gain Or Learn As A Result? |
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Program That Interests You |
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| Time Commitment |
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Most Volunteer shifts are weekly commitments, and run 4 hours in length. It is best when a volunteer can make a total commitment of at least 100 hours over several months to ensure continuity and adequate training. |
Please Check The Days You Would Be Available For Volunteer Assignments: | |
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Hours Available To Volunteer (Some Departments Hours Vary) | |
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| APPLICATION DISCLOSURE/RELEASE FOR VOLUNTEER PROGRAM SERVICES |
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Pursuant to the requirements of the Fair Credit Reporting Act, notice is given that a consumer report* may be made in connection with your application for Volunteer Services. If you are selected by Presbyterian Hospital of Rockwall you are also granting permission for us to periodically obtain other consumer reports as may be needed for purpose of your participation in the Volunteer Services Program.
If you are denied participation - either wholly or partly, because of information contained in a consumer report - a disclosure will be made to you of the name and address of the consumer reporting agency making such report. You will also receive a copy of the report and a statement of your consumer rights.
By submitting the information below you consent to the procurement of a consumer report in connection with your application for Volunteer Services. |
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Gender |
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List All Of The Counties (Including City & State) You've Lived In For The Last Seven Years |
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| Have You Lived Anywhere In The Last 7 Years Where You Did NOT Receive Any Bills Mailed In Your Name? If So, What County & State Was Involved? |
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| SIGNATURE |
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| I understand that I am applying to be a volunteer, not a paid employee, within Texas Health Presbyterian Hospital Rockwall. (PHR) I agree that I am not actively seeking employment from this volunteer experience. I understand that I am authorized solely to perform tasks assigned specifically to me. I agree to abide by the rules and regulations of PHR, including the Drug Free Workplace Policy, and agree that my volunteer services may be discontinued at any time. I understand that all information concerning this hospital and its patients is strictly confidential, and I hereby agree to maintain this confidentiality. I authorize references and prior employers to provide all information they may have concerning me to PHR and I release all parties from any and all liability or claims for damage whatsoever that may result. I understand that misrepresentation or omission of the facts called for hereon, receipt of unsatisfactory references, or failure to pass a required drug screening will be sufficient cause for the rejection of my application for Volunteer services from PHR. I understand that as a volunteer of Texas Health Presbyterian Hospital Rockwall, I may not provide volunteer services that involve direct patient care, and I may not provide volunteer services that require a license or certification. In addition, as a condition of volunteer placement, I may not solicit physicians or other clinical staff for “shadowing” or other educational opportunities. Such behavior may result in termination from my volunteer assignment. |
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