You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.

Please enter any questions or comments you have at this time.

As a member of the Methodist Health System Volunteer Services, I understand the services I provide are without pay or other employee benefits, and I am not authorized to do anything directly to or for the patient that requires the knowledge and/or actions of a licensed professional hospital employee.

1.  I am not entitled to participate in any employee benefit plans, nor am I covered under any workers' compensation or liability insurance policy or program of Methodist Health System or any of its hospitals or affiliated entities.
2. By submitting this application I hereby assume the full risk of my activities as they relate to my participation in the volunteer program at any Methodist Health System facility.
3. I hereby authorize any physician, hospital or insurance carrier to release to the volunteer program at Methodist Health System all medical information pertaining to my physical ability and/or limitation to perform work functions. I understand that the reason for the disclosure of my medical information pertaining to my physical ability and/or limitation to perform work functions. I understand that the reason for the disclosure of my medical information is for the sole purpose of providing necessary and relevant information to Methodist Health System to ensure my ability to work safely without an unreasonable risk of injury to myself or others and to comply with applicable government regulations.
4.  I hereby agree to release, indemnify, defend and hold harmless the volunteer center, the volunteer program, Methodist Health System, all of their officers, directors, agents, employees, servants, representatives, and attorneys from any and all claims or causes of action of any kind (including claims arising out of the actual or alleged negligence, or the actual or alleged strict liability of the volunteer center, the volunteer program, and/or Methodist Health System).
5. I hereby agree to abide by all rules, policies and guidelines of Methodist Health System, whether verbal or written, while providing volunteer services at Methodist Health System or any affiliated entities. I agree to wear appropriate attire, including an identification badge identifying me as a volunteer, all as requested by Methodist Health System.
6. I understand and agree that Methodist Health System may require me to immediately withdraw from providing any and all volunteer services in the event my conduct, demeanor or cooperation is unsatisfactory to Methodist Health System, in Methodist Health System's sole discretion.
7. I hereby agree that to the extent the volunteer services I perform cause me to gain knowledge of confidential patient and/or business information, I will not disclose or produce any confidential patient and/or business information outside the volunteer services which I am providing to Methodist Health System unless expressly authorized by Methodist Health System in writing. I acknowledge and understand that unauthorized access, use, disclosure of reproduction of any patient information in violation of this agreement may result in my immediate removal from Methodist Health System facilities. I agree that I will take appropriate steps to protect any confidential patient information that I gain access to while providing the volunteer services. I agree to notify Methodist Health System of any violations of the agreements I have made or any improper uses or disclosures of confidential patient information by anyone.
8. I agree that nothing in this application or the agreements I have made changes nor should be interpreted to change my status as a volunteer of Methodist Health System.
9. I represent and warrant that I have read this application and thereby agree to all terms and conditions stated herein of my own free will, and agree to be bound hereby for all times during and after my volunteer analysis services are completed. Pursuant to the requirements of the Fair Credit Reporting Act, I have been given notice that an investigative consumer report may be made in connection with my application. If I am denied the opportunity to provide volunteer service, either wholly or partly because of information obtained in a consumer report, a disclosure will be made to me of the name and address of the consumer agency making such a report. I authorize my personal references/volunteer organizations to provide any information they may have regarding me and release them and Methodist Health System from all liability for any damage whatsoever for providing or obtaining this information whether or not it is on their records. Failure to satisfactorily comply with the rules, regulations, and guidelines of Volunteer Services and the hospital may be cause for termination of services. I understand all applicants are considered without regard to race, color, religion, national origin, age, sex, disability, marital status, or ancestry.

I certify that the information on this application is complete and correct to the best of my knowledge.  I also understand and agree that submitting this application form does not automatically register me as a Methodist Midlothian Medical Center volunteer, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering.

Checking the box below shall have the same force and effect as my signature and submitting this application form, I agree to all terms and conditions stated herein. If you do not check the box below, your application will be considered incomplete and will not be processed.