Dear Prospective Volunteer:
Thank you for your interest in Southwest General Hospital's Volunteer Program.
Attached please find the:
 Volunteer Application & Agreement
 Volunteer Check List & Agreement
 Parental Medical Consent*
 Background Check Disclosure and Consent Form
*A prospective volunteer must be 17 yrs old or older. Applicants younger than 18 year old are required
to secure parent or legal guardian’s permission by completing the attached Parental Consent form.
Applicants 18 years & older do not require the Parental Consent form.
All completed forms can be sent to Human Resources by fax or mail:
Fax at (210) 921-3450
Southwest General Hospital
Attn: Human Resources
7400 Barlite Blvd.
San Antonio, TX 78224
Or simply stop by the hospital and deliver it to the hospital’s Human Resources department.
Once the completed paperwork is received, the next steps are as follows:
1. Human Resources (background check)
2. Occupational Health Nurse (TB/drug test/medical screening). A current copy of your
immunization record and recent TB test result – less than 12 months old – may help
expedite this process.
3. Orientation and training in your volunteer area with the department director.
The prospective volunteer must pass each section to become a volunteer.
Due to the financial investment involved in approving any prospective volunteers, and to
ensure your volunteering experience with Southwest General Hospital is a valuable learning
experience for you, volunteers are asked to commit to a minimum of 100 volunteer hours over
the course of six months to one year.
We look forward to working with you and know you will find our Volunteer Program rewarding.
Sincerely,
The Southwest General Hospital Team
Rev 09/2015
Volunteer Application & Agreement
Date_______/_______/______
First Name_______________________
Last Name___________________________________
Social Security #____________________ Birth Date: _______/______/____
Age: ________ (Please
remember if you are not 18 years old the parent consent form needs to be completed by your parent or guardian and
returned with the volunteer application and agreement).
Address:__________________________________ City: _____________ State _____________
Zip Code: ________________ Email Address: _______________________________________
Home Phone #:______________________________ Cell Phone:________________________
In case of emergency, please indicate who could authorize medical care below.
Name: _______________________________________ Relationship: ____________________
Address: ____________________________________ Phone: __________________________
Work/Volunteer Experience: ________________________________________________________
_______________________________________________________________________________
Skills, Abilities and Languages spoken:
___________________________________________________________________________________
___________________________________________________________________________________
_______________________________________________________________________
How did you learn about Southwest General Hospital?
_______________________________________________________________________________
Volunteer interests (please check all that apply)
Gift Shop
Information Desk
Day Surgery Waiting Room
Administrative Support
Emergency Room
Other____________________________
Availability:
Months____________________________________________
Preferred Day(s) and Hours: ___________________________
Rev 09/2015
Patient Escort
The BirthPlace
Please list the names and addresses of two personal references:
Name: ______________ Address: _______________________ Phone #: ___________
Name: ______________ Address: _______________________ Phone #: ___________
I hereby authorize Southwest General Hospital to conduct a background check, drug screen
and TB skin test as a condition of my acceptance into the hospital’s volunteer program.
I agree to participate in New Volunteer Orientation, any job specific instruction, and the Annual
Orientation as required by the hospital.
I shall hold as absolutely confidential all information that I may obtain directly or indirectly
concerning patients, doctors or personnel, and not seek to obtain confidential information from
a patient.
My services are donated to the hospital without contemplation of compensation or future
employment, and given with humanitarian or charitable reasons.
I shall not sell or attempt to sell goods or services, request contributions, or solicit persons to
sign or distribute political petitions on hospital premises, unless I receive the express
authorization of the Director of Marketing to engage in these activities.
I shall at all times uphold the philosophy and standards of the hospital.
I shall be punctual and conscientious, conduct myself with dignity, courtesy and consideration
of others, and endeavor to make my work professional in quality.
I understand that the Identification Badge issued to me is the property of the hospital, and I
agree to return it upon leave of absence, termination of volunteer service or whenever
requested by staff to do so.
I have read each of the above conditions and I agree to be bound by them.
Printed Name: __________________________________________
Signature: _________________________________________Date:___________________
Rev 09/2015
Volunteer Check List & Agreement
Please initial the following statements:
_________ I authorize Southwest General Hospital to conduct & evaluate the results of
Health Screen, Drugs Screen & Background Check as a condition of my
Acceptance for volunteer service. I have received & completed the Disclosure &
Consent form.
__________ I agree to participate in training, including orientation & Job-Specific
instruction.
__________ I agree not to divulge or discuss Confidential Information that I may learn
about Southwest General Hospital's, staff, patients, visitors or volunteers.
__________ I agree to abide by all policies & Guidelines of the Volunteer Services
Department, Southwest General Hospital & IASIS Healthcare.
__________ I understand that the identification Badge & Uniform issued to me is the
property of Southwest General Hospital, & I agree to return it upon termination of
volunteer service.
Volunteer Acceptance:
Printed Name: ________________________________________________
Signed Name: ________________________________________________
Date: _________________________
Rev 09/2015
Parental Medical Consent
Only complete if volunteer applicant is a minor.
The Parties of this agreement are:
THE PARENT(S)/GUARDIAN(S)
Full Name & Surname:
______________________________________________________________
Identity/Social Security or Other (Specify) Number:
______________________________________________________________
Physical Address:
______________________________________________________________
______________________________________________________________
Emergency Telephone Number:
______________________________________________________________
Contact Details:
______________________________________________________________
(Hereinafter referred to as "The Parent/Guardian")
THE CHILD
Full Name & Surname:
________________________________________________________________
Birth Date/Identifying Number:
________________________________________________________________
(Hereinafter referred to as "the Child")
This consent also acts as authorization given to minor child to participate in Southwest General
Hospital's volunteer program. The volunteer hours per week will not exceed 15 hrs. Also,
student volunteers will not work later than 7pm. This authorization also gives consent by
parent/guardian to allow Southwest General Hospital to administer any drug and alcohol
testing. This consent also allows SWGH to administer & read the TB testing that is provided
free of charge.
Thank you!
Signature_____________________________________ Date: ______________
(Parent/guardian)
Rev 09/2015