Volunteer Application

MSSVC VOLUNTEER APPLICATION FORM

Name of Individual or Group Contact person:
First name:  Last name: 
Mail Address: 
 
 
City:  
State:   
 Zip Code:
Home Phone: Best time to call: 
Email address: How did you find out about volunteer oportuninies with our facility:
Date of Birth: Social Security No: 
1.) Are you over 14 y ears of age? Yes No

2.) Why do you want to be a volunteer?
3.) What type of volunteer work do you prefer?
4.) Would you accept another assignment for which you will receive training? Yes No
5.) List previous vounteer experience:

6.) Are you presently employed? Yes No
If yes, complete the following:

Name of Employer:
Occupation:
Address of Employer:
Full Time or Part Time:

 
7.) Are you presently enrolled in a school, college or university? Yes No
If yes, complete the following:
Name of School/College/University:
Name of Teacher/Professor:
Name of Class/Course:
Class Credit
Yes No  
8.) Indicate the days and times that you would be available to volunteer:
MONDAY
TUESDAY
WEDNESDAY
THURDAY
FRIDAY
SATURDAY
SUNDAY
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
9.) Start date
Month
Day
200
and lenght
Month
Days
Years
of commitment?
10.) Are you or any members of your family currently receiving TDMHMR services? Yes No
11.) Have you been convicted of any type of criminal offense or been listed as revoked in the Nurse Aide Registry or listed as unemployable
in the Employee Misconduct Registry? Yes No
12.) Have you lived at any time during the last two years outside the State of Texas? Yes No
13.) List ways by which you like to receive recognition:

14.) Do you speak any language other than English? Yes No
If yes, please list:
 

15.) Are you fluent in sign language? Yes No
16.) List your interests, hobbies, community activities:
17.) Have you taken a Defensive Driving course withing the past three years? Yes No

18.) Can you furnish transportation for others? Yes No
If yes, does your vehicle have:
Required Insurance
Inspection Sticker
 
Child Safety Seat
License Tags
Driver's Lic. #
Have you had any moving violations in the past 2 years?
Yes No

VOLUNTEER AGREEMENT

I affirm that the information that I have provided is true and correct to the best of my knowledge. I agree to conform with the Texas Department of Mental Health & Mental Retardation rules and regulations. I also agree to respect the confidential nature of case information as well as information obtained as a result of personal contacts with clients.
I understand that criminal history and registry checks will be conducted before my volunteer placement begins. I further agree to inform the department if I am named in complaints or indictments or convicted of offenses (see Item 11 above). I understand that I will begin service on a reciprocal trial basis and agree to participate in orientation and training. I also understand that volunteering provides no promise of future employment.
I agree