Volunteer Application

First Name MI Last Name:
E-Mail Home Phone
Work Phone Cell Phone
Address City:
State Zip Code:
Social Security #: Birthday:
Driver's License #: Issuing State:
Name of Spouse: Are you retired?:
If retired, who was your last employer?
 
In case of emergency, please indicate who could authorize medical care; we must have information about a relative/friend living in the area:
Name: Address:
Home Phone Work Phone:
 
What days and times are you available to volunteer:
Monday Thursday Sunday Mornings
Tuesday Friday     Afternoons
Wednesday Saturday     Evenings
 
Please list your past and current volunteer experiences:
Organization Name: Your Position:
Organization Name: Your Position:
   
 
What did you like most about your volunteer experience?
 What did you like least?
 
Please check all statements that you believe applies to you. This information will help us find the kind of volunteer experience that might be of interest to you.
I prefer to work alone I prefer to do office work
I prefer to work in a group I prefer to work directly with a staff person
I prefer routine tasks I prefer an opportunity to meet and get to know other people
I prefer to do whatever is needed I prefer to work one-on-one with patients
 
Please check below the areas in which you are experienced or have a desire to learn:
Accounting Leadership
Bookkeeping Patient Care
Cashiering Telephone (answering/calling)
Computer skills/word processing Filing
Crafts (crochet, knitting, sewing, flower arranging, making ribbons, etc.) Other (please specify)
 
Why are you interested in volunteering at Seton Medical Center Williamson and what would you like to get out of your experience?
 How did you hear about volunteering at Seton Williamson?
 
Are you volunteering as part of Community Service requirement that is a condition of your probation or parole?
If yes, was your offense a misdemeanor or a felonty, and in what county were you convicted?
 

Consent for Criminal Background History Check

I hereby give permission for the Seton Medical Center Williamson Volunteers and the Volunteer Services Office 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 an employment/volunteer position with this organization. I also understand that as long as I remain an employee or 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 the Seton Medical Center Williamson Volunteers and the Volunteer Services Office, 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:

Sex: Social Security Number: Date of Birth:
Have you ever been convicted of a crime and are there any legal charges pending against you?

If yes, please explain: