Volunteer Services Adult Application

First Name

Middle Name

Last Name

Address

City

State [Choose]ALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWY    Zip

Home Phone Number    (xxx-xxx-xxxx)

Cell Number    (xxx-xxx-xxxx)

Email Address

Sex [choose one] male female

Birthday (choose one) 01 02 03 04 05 06 07 08 09 10 11 12   (choose one) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   (choose one) 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Preferred method of communication  Post Mail Email

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 [Choose]ALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWY    Zip

Home Telephone    (xxx-xxx-xxxx)

Work Telephone    (xxx-xxx-xxxx)

Please list languages in which you are fluent:

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

Why are you interested in volunteering at the Seton Family of Hospitals and what would you like to gain from your experience here?

How did you hear about our Volunteer Program?

Please list the names of any friends or relatives who volunteer at Seton:

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.

Last Name

First Name

Middle Name

Yes No 

If yes, please explain: (Please note: Seton HealthCare Family does not participate in court ordered community programs.)