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Mother Frances Hospital
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Trinity Mother Frances Hospitals and Clinics
Volunteer Application / Respite Care Provider Form

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.

Please read the following and place your name and date at the bottom of this form signifying that you agree:

I hearby allow Trinity Mother Frances to perform a check of my background including criminal record, personel 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 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 Trinity Mother Frances (TMF). I understand that all information concerning TMF and its patients is strictly confidential, and I hereby agree to maintain this confidentiality. I agree to accept full responsiblity and to hold harmless 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 postition 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.

* Indicates required information
Salutation * 

First Name * 
Last Name * 
Social Security Number (Please Include Dashes) * 
Address * 
City * 
State * 
Zip * 
Email * 
Home Phone * 
Daytime Phone 
Date of Birth * 
Driver's License Number 
Employed or Retired or Student? * 

Work hours and days 
Date of current employment 
Employer's Phone 
Completed education 
Limitations to health? 
Contact Name in case of an emergency * 
Emergency contact home phone 
Emergency contact work phone 
Do you want to volunteer once a week to help people? 
When are you available to volunteer? 

What school do you attend? 
What is your instructor's name? 
Do you want to job shadow? 
Have you ever worked for Trinity Mother Frances Hospitals and Clinics or an affiliated organization? (Include dates, titles, former name and affiliated organization) 
Required Reference 1 (other than family member) 
Name * 
Phone * 
Address * 
City * 
State * 
Zip * 
Required Reference 2 (other than family) 
Name * 
Phone * 
Address * 
City * 
State * 
Zip * 
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? * 

If Yes, explain fully 
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?) * 

If Yes, explain fully 
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? * 

If Yes, please explain circumstances 
I understand and agree to the stipulations explained at the top of this form: 
Full Name * 
Date *