Adult Volunteer Application

Please indicate the Houston Methodist site you are looking to volunteer at.

Personal information

* Last name

* First name

* Address line 1

Address line 2

* City

State

* ZIP code

* email

What is the best phone number to reach you at?

Home phone

Cell phone

Home phone

Cell phone

* Date of birth

Gender

Emergency Contact

* Contact name

* Relationship

Home phone

Cell phone

Education & employment

Are you retired?

Are you currently a student?

Are you currently employed?

Employment information

Current employer

Phone

May we call you during normal buisness hours?

Position

What hours do you work?

Employment experience

Education

Highschool

Trade school

College

Major

What year do you plan to graduate?

Additional information

* Please tell us why you want to volunteer at Houston Methodist.

Please list your prior volunteer experience.

Do you have any skills, talents, hobbies or interests that could benefit our volunteer program?

Interest in participating in extra projects and/or special events

Do you speak any additional languages?

How did you hear about our program?

If you choose other, please let us know where you hear about us in the field below.

Are you currently serving or a veteran of the armed services?

Do you have a friend or family member who currently works at Houston Methodist?

* What is the name of the friend/family member?

* What department does the friend/family member work in?

Availability

Please check the boxes that apply. Depending on the location you have selected there will be limited opportunities on the weekends.

Monday

Morning

Afternoon

Tuesday

Morning

Afternoon

Wednesday

Morning

Afternoon

Thursday

Morning

Afternoon

Friday

Morning

Afternoon

Saturday

Morning

Afternoon

Sunday

Morning

Afternoon

Are you able to commit to at least one year of service, which can include up to one- to four-hour shifts per week depending on placement?

If, 'No' - What length of time are you able to commit to volunteering?

* What length of time are you able to commit to?

Conclusion

Will you agree to practice the following while serving as a volunteer at Houston Methodist?

I CARE VALUES (Integrity, Compassion, Accountability, Respect, Excellence)  - Integrity - We are honest and ethical in all we say and do.- Compassion - We embrace the whole person and respond to emotional, ethical and spiritual concerns as well as physical needs.- Accountability - We hold ourselves accountable for our actions.- Respect - We treat every individual as a person of worth, dignity and value.  - Excellence - We strive to be the best at what we do and a model for others to emulate.

Will you agree to an annual TB test?

Will you agree to an annual yearly flu shot?

Will you agree to a drug screening and a background check prior to serving as a volunteer?

I am aware that a uniform is required and will consist of black or khaki slacks (no jeans, shorts or capris) with the volunteer jacket/vest along with closed toe shoes. You must wear a collared shirt with your volunteer jacket/vest. There may be a cost involved of $20.00. Please let us know if there is any financial hardship in obtaining this uniform.

Conviction will not necessarily bar volunteer service

Public Law 91-508 requires that we advise that a routine inquiry may be made which will provide information concerning your character, reputation and personal characteristics, and mode of living. You may obtain a copy of this information upon written request.

I hereby certify that the information I supplied in this application is true, complete and correct to the best of my knowledge and I understand that any information I withheld or falsely provided in connection with the foregoing shall be cause for rejection of this application or termination of volunteer status. I hereby authorize The Houston Methodist System, without liability, to contact prior employers (present employers if authorized) schools or references I have given and authorize said employers, schools or reference to make full response to any inquiries by The Methodist Hospital System in connection with this application for volunteer service.

Confidentiality Agreement

I agree to use confidential or proprietary information only as needed to perform my volunteer duties. This means I will not access confidential or proprietary information without legitimate need/permission, nor in any way divulge, copy, release, sell, lend, revise, alter, or destroy any confidential or proprietary information belonging to Houston Methodist. I understand that I will be automatically dismissed as a volunteer if I do not respect my responsibility for maintaining confidentiality.

Immigration, Export Control Laws and Regulations Compliance

It is the policy of Houston Methodist System to comply with all Immigration and Export Control Laws and Regulations. Therefore all Visitors, Students, Observers, Volunteers and other Unpaid Persons providing services or participating in activities at Houston Methodist Hospital System must complete this questionnaire before being granted access to our facilities.

1.    Without specifying a particular category, do you fall into any one of the following U.S. citizenship/immigrant categories: (i) U.S. citizen or national; (ii) Lawful permanent resident (i.e. green card holder) of the U.S.; (iii) Person granted U.S. refugee or asylee status?

2. If you answered "No" to Question #1,

Please indicate if you are a national, citizen, or permanent resident of one or more of the following countries: Cuba, Iran, North Korea, Sudan, or Syria.

Cuba

Iran

North Korea

Sudan

Syria

If accepted as a Houston Methodist Volunteer, I agree that:

I will use confidential information only as needed to perform my volunteer duties. I will not access confidential information without legitimate need/permission, nor in any way divulge, copy, release, sell, lend, revise, alter or destroy any confidential information belonging to Houston Methodist. I understand that I will be automatically dismissed as a volunteer if I do not respect my responsibility for maintaining confidentiality. My services are donated to the hospital and given for humanitarian, religious or charitable reasons. I understand that it is a crime to solicit business for attorneys. I shall not solicit any business for attorneys or insurance companies, both on or off of hospital property, or act as a runner or capper for an attorney in the solicitation business. I shall report all known occurrences of solicitation for attorneys to the Volunteer Services Office. I shall not sell or attempt to sell goods or services, request contributions, or solicit persons to sign or distribute political petitions on hospital premises unless I receive the express authorization of the Volunteer Services Office to engage in these activities. I shall submit to physical screenings, which may include chest X-ray, skin tests, and appropriate laboratory tests, as a condition of my acceptance into the volunteer program. I also authorize the person(s) performing tests or x-rays films to report the results to the hospital. I shall be punctual and conscientious, conduct myself with dignity, courtesy, and consideration of others, and endeavor to make my work professional in quality. I shall attempt to resolve any problems related to my volunteer activities with my unit/department supervisor, and, if unsuccessful, attempt to resolve any such problems with the Volunteer Services Office. I shall make my best effort to fulfill my commitment to the hospital by completing all assignments that I accept. I shall at all times uphold the mission of the hospital. I understand that the Volunteer Services Department reserves the right to terminate my Volunteer status as a result of Failure to comply with hospital policies, rules and regulations; three (3) absences without prior notification; unsatisfactory attitude, work or appearance; or any other circumstances which, in the judgment of the Department Director, would make my continued service as a volunteer contrary to the best interests of the hospital.

[ clear ]

Signature