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. 
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Do you want to

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?

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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?

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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 adjucation or dropping of the charge?)

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Emergency Contact
 
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