Dell Children’s Medical Center of Central Texas
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Volunteer Application

If you are interested in volunteering please complete the form below:

Fields outlined in orange are required.

I am applying as a:

College Volunteer (Over the age of 18 and currently enrolled in an accredited 4 year University)
Adult Volunteer (Over 18)


I
First Name
Middle Name
Last Name
Address
City
State    Zip
Home Phone Number    (xxx-xxx-xxxx)
Cell Number    (xxx-xxx-xxxx)
Email Address
Sex
Birthday    
Preferred method of communication    
If you are currently employed, please list your employer
Spouse’s/Partner’s Name
Please list your Spouse’s/Partner’s employer
Emergency contact
Address
City
State    Zip
Home Telephone    (xxx-xxx-xxxx)
Work Telephone    (xxx-xxx-xxxx)
II

What days and times are you available to volunteer:











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Please note:
The Director of Volunteer Services, after consulting with the Volunteer President, has the right to dismiss a volunteer at any time for any reason, including inappropriate behavior, failure to follow Seton policies and procedures, and or unreasonable conflicts with patients, staff, or visitors.

III

Please list your past and current work and volunteer experiences:

Organization name
Your position
Organization name
Your position
What did you like most about your work/volunteer experience?
What did you like least?
Number of years in the workforce
If retired, who was your last employer?
Other organizations to which you belong
IV
Why are you interested in volunteering at the Seton Family of Hospitals and what would you like to gain from your experience here?
V
How did you hear about our Volunteer Program?
VI
Please list the names of any friends or relatives who volunteer at Seton:
VII

Please list 3 references other than relatives:

1. First Name    Last Name
Home number    E-mail address
2. First Name    Last Name
Home number    E-mail address
3. First Name    Last Name
Home number    E-mail address
VIII

Volunteer Agreement

I, , agree to the following:


Consent for Criminal Background History Check

I hereby give permission for Seton Family of Hospitals to obtain information relating to my criminal history record through the Texas Department of Public Safety. The criminal history record, as received from the reporting agencies, may include arrest and conviction data as well as plea bargains and deferred adjudication. I understand that this information will be used, in part, to determine my eligibility for a volunteer position with this organization. I also understand that as long as I remain a volunteer here, the criminal history records check may be repeated at any time. I understand that I will have an opportunity to review the criminal history and a procedure is available for clarification, if I dispute the record as received.
I, the undersigned, do, for myself, my heirs, executors and administrators, hereby remise, release and forever discharge and agree to indemnify Seton Family of Hospitals, and each of their officers, directors, employees, and agents harmless from and against any and all causes of action, suits, liabilities, costs, debts, and sums of money, claims and demands whatsoever, and any and all related attorneys’ fees, court costs, and other expenses resulting from the investigation of my background in connection with my application to become a volunteer/staff member.

Enter Your Current Legal Name

Last Name
First Name
Middle Name

Enter any previously used names below:

Have you ever been convicted of a crime and are there any legal charges pending against you?

If yes, please explain:

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