Download Report

Dear Prospective Volunteer,
We are excited that you are interested in becoming a member of our volunteer family. You will
be joining a team of dedicated people from our community who donate their time in service to others.
As a volunteer you can be an invaluable complement to the care provided here and an indispensable
part of our Driscoll Children's Hospital family.
Please do not fill out a Volunteer application if:
You need any practicum hours or school requirement hours (Nursing, Social Work,
Child-Life Specialist, Marketing, Pharmacy etc.). Please contact the Center for
Professional Development and Practice Department at 694-5068 or send an email to
[email protected].
We ask that prospective Volunteers commit to at least one 4-hour shift per week for at least 6 months
in one of our core areas listed in the enclosed brochure. Take a minute to review the Auxiliary brochure
and begin thinking about what areas of service interest you.
Because we are a children's hospital, we do require three written non-relative references and a
Criminal Background Check. When we have received your completed application with your three
references we will contact you for a personal interview to discuss volunteer opportunities at Driscoll
Children's Hospital.
Please return the following in the enclosed envelope:
*Completed application including all three references filled out by non-related adults.
*Signed Background Verification Disclosure/Completed Background Request Form
Incomplete applications will be returned.
We are delighted that you share our interest in volunteering and should you have any questions, please
call our office at (361) 694-5011 or e-mail us at [email protected]. For additional information you
may also visit our website: www.driscollchildrens.org.
Sincerely,
Volunteer Services Department
1
OFFICE USE ONLY
App Sent ____________
Reference 1__________
Reference 3__________
Reference 2__________
Interview Date _______
App Received ____________
Background Sent _________
3533 South Alameda
Corpus Christi, Texas 78411
Office: (361) 694-5011
Fax:
(361) 808-2096
Volunteer Application
Last Name:
First Name:
MI:
Home Telephone:
Work Phone:
Cell Phone:
E-mail Address:
Current Address:
Permanent Mailing Address (if different from current):
Street
Street
City State Zip
City State Zip
Are you 18 years or older?  Yes  No
Other than minor traffic offenses have you ever been 1. Convicted of a crime (misdemeanor or felony), 2.
Received a probated sentence (including deferred adjudication) for an alleged crime, 3. Been assigned a
probation officer, or 4. Plead guilty, no contest, or nolo contendere to an alleged crime? A yes response will not
necessarily disqualify an applicant from volunteering.  Yes  No If yes, please explain, attach additional
pages if necessary:
College:
If you are currently a student, please complete this section.
Semester Hours Complete:
Major:
Employment History (Most recent first)
Company:
Position:
Duties:
Company:
Position:
Duties:
Do you have any relatives currently employed at Driscoll Children’s Hospital?  Yes  No
If yes, Name:
Relationship:
Extension:
2
Volunteer and Community Activities
Agency/Organization:
Position:
Dates:
Please list any friends or relatives who volunteer at Driscoll Children’s Hospital:
Please list any special skills or interests:
Computer Literate:
Additional Languages:
Where did you learn about the volunteer opportunities at Driscoll Children’s Hospital? (check all that apply)
 Driscoll Children’s Hospital
 As a Driscoll Parent/Family
Website
 Radio/TV
Member
 Other Website
 Family/Friend
 As a Driscoll Patient
 Brochure/Flyer
 Driscoll Volunteer
 Other:
I verify that the information provided is accurate to the best of my knowledge. I authorize DCH and its agents to
confirm all information provided on the application. I release DCH and all persons and companies from any
claims, liabilities or damages from obtaining or furnishing information about me.
Applicant Signature:
Date:
3
Application and Background Disclosure Form
Pursuant to the requirements of the Fair Credit Reporting Act, notice is given that a consumer report* may be made in
connection with your application for employment/volunteering. If you are denied placement, either wholly or partly,
because of information contained in a consumer report, a disclosure will be made to you of the name and address of the
consumer reporting agency making such report. You will also receive a copy of the report and a statement of your
consumer rights.
By signing below you consent to the procurement of a consumer report* in connection with your application for
employment/volunteering and/or continued employment/volunteering.
_______________________________________________
Signature
____________________________________
Date
General Information
Applicant's Name: _______________________________________________________________
Applicant's Other Last Names Used: _________________________________________________
Address(No P.O. boxes)___________________________________________________________
City __________________________State:_________________ Zip ________________________
Security Number: _________-_________-__________ Date of Birth: _______/________/________
Driver’s License No. _______________________________________________ State: _________
Education Verification:
College/University:_______________________________ City:__________________ State:______
Degree:___________________________________ Graduation Date:______/________/________
List all of the cities (including state and county) lived in for the last SEVEN YEARS.
CITY
STATE
COUNTY (do not enter USA)
1
2
3
4
5
*A consumer report may consist of employment records, educational verification, licensure verification, driving
history, previous addresses, and other public records relative to criminal charges. A credit report will not be
requested unless it is deemed pertinent to the functions of the position for which you are applying.
4
BACKGROUND VERIFICATION DISCLOSURE
As part of the employment/volunteer application process, Driscoll Children’s Hospital (DCH) has chosen to
obtain a form of consumer report, a criminal record check and GSA Debarred list and/or DHSS Cumulative
Sanctions list, on applicants check on applicants whose employment would require driving. These checks
are performed under the federal Fair Credit Reporting Act to ensure a safe working environment.
Additionally, DCH may conduct further criminal record and motor vehicle record checks or obtain other
consumer reports, including investigative consumer reports that include information as to your character,
general reputation, personal characteristics, and mode of living, at certain times during
employment/volunteering, such as when employees/volunteers are evaluated, or when
employees/volunteers apply for transfer or promotion. If an investigative consumer report is prepared,
you have the right to request in writing complete and accurate disclosure of the nature and scope of the
information requested and a summary of your rights as a consumer under the Fair Credit Reporting Act.
AUTHORIZATION AND RELEASE
I acknowledge receipt of this notice and authorize DCH and its agents to obtain consumer reports on me,
including criminal record, GSA Debarred list and/or DHHS Cumulative Sanctions list, and motor vehicle
record checks or investigative consumer reports that may include information as to my character, general
reputation, personal characteristics, and mode of living, for employment/volunteer purposes at any time
during my employment/volunteering or as part of DCH’s pre-employment/volunteer background
investigation. I understand that this consumer report will be obtained under the federal Fair Credit
Reporting Act and will be used to determine my suitability for employment/volunteering.
I understand that DCH requires me to consent to the consumer report and provide certain identifying
information to facilitate the record check process as a condition of employment/volunteering. I also
understand that failure to consent to credit, criminal record or motor vehicle record checks or other
consumer reports, including investigative consumer reports, will result in ineligibility for
employment/volunteering or termination of employment/volunteering.
I authorize any person, organization, governmental authority, or other party to release and disclose
information and cooperate in the obtaining and producing of consumer reports on me. If I am hired, this
authorization shall remain valid and shall serve as an ongoing authorization for DCH and its agents to
obtain consumer reports on me, including criminal record and motor vehicle record checks, for
employment/volunteer purposes at any time during my employment/volunteering. I understand that if an
investigative consumer report is prepared, I have the right to request in writing complete and accurate
disclosure of the nature and scope of the information requested and a summary of my rights as a
consumer under the Fair Credit Reporting Act.
_______________________________________________
Signature
____________________________________
Date
5
Greetings from Driscoll Children's Hospital!
Your name has been provided as a reference by _________________________ who submitted an application to our
Volunteer Services Department at Driscoll Children's Hospital. The information that you provide will allow us to make an
informed decision on the applicant's ability to fulfill the responsibilities involved in our volunteer program.
Please return this completed form to the applicant as soon as possible. Thank you.
Reference 1
Name:
Street Address:
City, State, Zip:
Daytime Phone:
Evening Phone:
How long have you known the Applicant? ________________________________
In what capacity have you known the Applicant? ___________________________
Would you share with us any knowledge you have of this person in relation to his/her ability to be accepting of and
sensitive to the needs of children?
Describe the applicant's reliability and willingness to make a commitment such as this:
Are you aware of any physical or emotional problems that would limit the applicant from fulfilling volunteer responsibilities
in a children's hospital? ____Yes ____ No
Please remember our patient population-CHILDREN-and give your careful thought before answering the following
question:
Would you recommend the applicant for placement in a setting such as ours?
 Yes, I recommend this applicant.
 No, He/She may be more suited for another type of volunteer agency.
Additional Comments:
Signature: __________________________________ Date: ______________
6
Greetings from Driscoll Children's Hospital!
Your name has been provided as a reference by _________________________ who submitted an application to our
Volunteer Services Department at Driscoll Children's Hospital. The information that you provide will allow us to make an
informed decision on the applicant's ability to fulfill the responsibilities involved in our volunteer program.
Please return this completed form to the applicant as soon as possible. Thank you.
Reference 2
Name:
Street Address:
City, State, Zip:
Daytime Phone:
Evening Phone:
How long have you known the Applicant? ________________________________
In what capacity have you known the Applicant? ___________________________
Would you share with us any knowledge you have of this person in relation to his/her ability to be accepting of and
sensitive to the needs of children?
Describe the applicant's reliability and willingness to make a commitment such as this:
Are you aware of any physical or emotional problems that would limit the applicant from fulfilling volunteer responsibilities
in a children's hospital? ____Yes ____ No
Please remember our patient population-CHILDREN-and give your careful thought before answering the following
question:
Would you recommend the applicant for placement in a setting such as ours?
 Yes, I recommend this applicant.
 No, He/She may be more suited for another type of volunteer agency.
Additional Comments:
Signature: __________________________________ Date: ______________
7
Greetings from Driscoll Children's Hospital!
Your name has been provided as a reference by _________________________ who submitted an application to our
Volunteer Services Department at Driscoll Children's Hospital. The information that you provide will allow us to make an
informed decision on the applicant's ability to fulfill the responsibilities involved in our volunteer program.
Please return this completed form to the applicant as soon as possible. Thank you.
Reference 3
Name:
Street Address:
City, State, Zip:
Daytime Phone:
Evening Phone:
How long have you known the Applicant? ________________________________
In what capacity have you known the Applicant? ___________________________
Would you share with us any knowledge you have of this person in relation to his/her ability to be accepting of and
sensitive to the needs of children?
Describe the applicant's reliability and willingness to make a commitment such as this:
Are you aware of any physical or emotional problems that would limit the applicant from fulfilling volunteer responsibilities
in a children's hospital? ____Yes ____ No
Please remember our patient population-CHILDREN-and give your careful thought before answering the following
question:
Would you recommend the applicant for placement in a setting such as ours?
 Yes, I recommend this applicant.
 No, He/She may be more suited for another type of volunteer agency.
Additional Comments:
Signature: __________________________________ Date: ______________
8