HealthBridge Children's Hospital - Houston, TX

 

 

 
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Volunteer Application
 

Contact Information    
     
Last Name  
First Name  
Middle Initial  
Social Security #  
Street Address  
City  
State  
Zip Code  
Home Phone  
Secondary Phone  
How were you referred?  
     
Dates Available to Volunteer    
     
Days  
Times  
Do you have any friends or relatives working or volunteering for HealthBridge?   Yes   No
Please explain  
Have you ever been convicted or have you pled guilty or no contest to a felony offense?   Yes   No
If yes, please explain  
Emergency Contact #1  
Emergency Phone #1  
Emergency Contact #2  
Emergency Phone #2  
Please explain why you want to volunteer at HealthBridge  
Area you would like to volunteer  
Do you speak, read or write in a language other than English?   Yes   No
If yes, please identify  
     
Employment and Volunteer History    
     
Company name  
Address  
Phone  
Job title of supervisor  
Duties performed  
Length of Service  
Hourly Rate (if applicable)  
Are you eligible for re-hire?   Yes   No
Reason for leaving  
     
     
     
Company name  
Address  
Phone  
Job title of supervisor  
Duties performed  
Length of Service  
Hourly Rate (if applicable)  
Are you eligible for re-hire?   Yes   No
Reason for leaving  
     
     
     
Company name  
Address  
Phone  
Job title of supervisor  
Duties performed  
Length of Service  
Hourly Rate (if applicable)  
Are you eligible for re-hire?   Yes   No
Reason for leaving  
     
Education    
     
High School Name  
Location  
Years Completed  
Graduate   Yes   No
     
College Name  
Location  
Years Completed  
Graduate   Yes   No
Course of Study  
     
Other School Name  
Location  
Years Completed  
Graduate   Yes   No
     
References    
     
Name  
Address  
Phone  
Relation  
     
Name  
Address  
Phone  
Relation  
     
Name  
Address  
Phone  
Relation  
     
Applicant's Statement    
     

I certify that all my answers given herein are true and complete. I understand that any misrepresentation or material omission that was made by me on this application will be sufficient cause for cancellation of this application, or immediate discharge, regardless of when it is discovered.

I fully authorize investigation of all statements contained within this application as may be necessary. I fully and completely RELEASE the facility, its owners and employees, and all previous employers and their employees, from any liability related to inquiries or responses made on my behalf and I request all prior employers, schools, governmental offices, and all other references included on this application, provide full and timely disclosures on my behalf.

I acknowledge that a criminal history background check may be conducted on me as a part of the application process and I understand that my authorization used above may be used in obtaining information regarding any prior convictions.

Finally, I also understand that if I volunteer, I will be required to provide proof of my identity within 3 days from my start date.

I represent and warrant that I have read and fully understand the foregoing and seek to volunteer under these conditions.

Signature (Name)  
Date  
     
   
     

 

 

 

 

 

  

HealthBridge

Children's Hospital - Houston
2929 Woodland Park Drive
Houston, TX 77082
Phone: 281.293.7774
Fax: 281.293.8117
 

 

 

Groundbreaking

HealthBridge Children’s Hospital—Houston

Expansion and Renovation Project

Anticipated completion date, January, 2008 read more

 

 

 

HealthBridge Children's Hospital - Houston has met all the requirements and complies with the standards set by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

 

 

 

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