Volunteer Application

If this is a medical emergency, please dial 911.

You will be called for an interview to match your interest and schedule to hospital needs. An orientation session will be planned for you to learn about the hospital and receive specific job instruction.

If possible, experienced volunteers will work with you until you are comfortable in your role.

First Name Last Name Address Address Line 2 City State Zip Social Security Number (don't include dashes) Email Primary Phone Date of Birth Employed or Retired or Student? Completed education? Limitations to Health? Have you ever worked for CHRISTUS Trinity Mother Frances? Do you want to Volunteer Job Shadow Have you ever been convicted of, been given probation or deferred adjudication in lieu of sentencing or pled no contest for any criminal offense (felony or misdemeanor) other than a minor traffic violation? Yes No If yes, please explain below Have you ever been convicted of any criminal offense related to healthcare or listed by a Federal agency as debarred, excluded, suspended or ineligible for Federal program participation? Yes No If yes, please explain below 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 of the charge?) Yes No If yes, please explain below Are you Military or Military Dependent? Do you consider yourself Hispanic or Latino? Which category best describes your race?

Emergency Contact

Contact Name in case of an emergency Relationship Emergency Contact Home Phone Emergency Contact Work Phone I understand and agree to the stipulations explained below.

Please read the following and check the box above signifying that you agree:

I hereby allow CHRISTUS Trinity Mother Frances to perform a check of my background including criminal record, personal reference, driving records, past employment history, physician or therapist as appropriate for the volunteer tasks in which I have expressed an interest.

I understand that I am applying to be a volunteer, not a paid employee, at CHRISTUS Trinity Mother Frances. I understand that I am authorized solely to perform tasks assigned specifically to me. I understand I must follow all rules and regulations of CHRISTUS Trinity Mother Frances (TMF). I understand that all information concerning CHRISTUS Trinity Mother Frances and its patients is strictly confidential, and I hereby agree to maintain this confidentiality. I agree to accept full responsibility and to hold harmless CHRISTUS Trinity Mother Frances, its affiliated entities, employees, directors, officers, trustees or agents from any and all claims and damages that may arise from my participation in the volunteer program.

I have read and understand the above and agree to comply with all rules and regulations of TMF and the Volunteer Services Department. I understand that failure to comply with such rules and regulations may be cause for my removal from the TMF volunteer program. I understand the Volunteer Service Department is not obligated to provide a placement, nor am I obligated to accept the position offered. I understand that my volunteer assignment is of no fixed duration and can be terminated by either party at any time with or without cause or reason. No offer of volunteer placement can constitute an agreement contrary to above.

I certify that all statements given on this application are correct and realize that omission, falsification or misrepresentation of any information on this application or any other personal record may result in not being placed in a volunteer position or in discharge, no matter when discovered. In the event I volunteer, I agree to abide by all present and subsequently issued procedures, policies, rules and regulations of the organization.

Your Health

Care Access

CONDITIONS & TREATMENTS

Volunteer Application

Emergency Contact