Student Volunteer Application Form

Please complete this application form if you are interested in becoming a Hill Country Memorial Hospital volunteer.

The fields indicated by an asterisk are required.

Note that you will need the address and at least one phone number for your emergency contact and your two references.

Once you complete the form, click the "Continue" button at the bottom of the form. Thank you for applying. Your future service is very valuable to Hill Country Memorial.

Application Disclosure

A background report is required of all volunteer applicants. This report may include checks of employment and education records, licensure and driving history, and other public records. Your full date of birth is requested for the purpose of obtaining a background report. Providing this information is voluntary and refusal will not subject you to any adverse consideration.

Note that a phone number is required for your emergency contact and references.

Name and Address

Fill in your legal name below. This information will ensure the accuracy of processing your background check as part of the volunteer application process.

First name:

Last name:

Middle name:

Title:

Street 1:

Street 2:

Street 3:

City:

State:

* Zip: *

Phone 1 phone:

* OK to call me here

Phone 2 phone:

OK to call me here

Phone 3 phone:

OK to call me here

Email address:

Date of birth:

(year optional)

Skills and Interests

Please check activities that you would be willing to use as a HCM volunteer.

Assignment Interests

As noted in the HCM web page, there are three main areas of volunteer activity; the Hospital and clinics, the Thrift Store, and Hospice. You may use the following section to indicate your work interests. Use the following examples as suggestions.
-Office or clerical assistance
-Patient and visitor assistance in the lobbies
-Preparing or delivering items for Hospice patients
-Assisting Thrift Store employees sort, repair, or sell donated items
-Assisting with Hospice visits or placing telephone calls
-Assisting the surgical or therapy teams as needed.

Availability

Please indicate the days and times you are usually available to volunteer. The usual volunteer time is 6:00 AM to 8:00 PM Mon.- Fri. for Hospital volunteers, 8:00 AM to 4:PM Mon.- Fri. for Thrift Store volunteers, and 9:00 AM to 4:00 PM for Hospice Volunteers.

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

From:

to:

Emergency Contact

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Phone 1 phone:

Phone 2 phone:

Phone 3 phone:

Relationship:

References

Please provide two references that we may contact.

1

2

First name:

Last name:

Middle name:

Street 1:

Street 2:

City:

State:

Zip:

Phone 1 phone:

Phone 2 phone:

Phone 3 phone:

Application Certification

I certify that all the information provided on this application is true, correct, and complete. I grant Hill Country Memorial permission to verify this information for the purpose of determining my volunteer acceptance.

I agree to abide by the regulations and policies of Hill Country Memorial if accepted. I understand that any acceptance is contingent upon the successful completion of background checks and health screening. I understand, if accepted, I will be required to complete other annual health requirements such as flu inoculations.

By clicking I Agree I am accepting the conditions and requirements as stated in the Application Disclosure and Application Certification statements listed above.

I Agree