Volunteer Profile - DOC

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					                                    Volunteer Profile
                    (To be completed by the prospective volunteer)

_________________________________ ___________________                          ___________________
                                  Social Security Number
Name                                                                           Today's Date
                                  *
_________________________________ ___________________                          ___________________
Current Address                   Day Phone                                    Evening Phone
_________________________________ ___________________                          ___________________
Permanent address                 Other Phone                                  Birth Date
if different from current address                                              If under 18, must also
                                                                               complete the Parental
                                                                               Consent form.
* The University of Texas Health Science Center at Houston (UTHSC-H) is requesting your social security
number (SSN) in order to expedite the criminal background check with the Department of Public Safety.
The UTHSC-H will not disclose a recipient’s SSN without the consent of the recipient to anyone outside the
University except as mandated by law.

Are you a Student? ______ Yes             ______ No

If Yes,



    1. Are your volunteer activities part of a school or any other formal program?

          ______ Yes        ______ No




    2. If Yes, please indicate the program or school name:

          _________________________________
   3. Will you require verification of your hours? ______ Yes ______ No




Are you a U.S. Citizen or U.S. Permanent Resident? _______ Yes       ______ No

If No,



   1. What is your current visa status in the U.S. that will permit you to volunteer with
      UTHSC-H? __________________

Note: If you are not a U.S. citizen or U.S. Permanent Resident, you will need to present
your original immigration documents to the Office of International Affairs to obtain the
appropriate administrative clearance before being cleared to Volunteer. The Office of
International Affairs is located in the University Center Tower, 7000 Fannin, Suite 130,
Houston, Texas 77030. Office telephone number is 713/500-3176.

Have you previously volunteered with UTHSC-H? ______ Yes             ______ No

If Yes, please indicate:

Volunteer Dates    From _______ To _________

Department    __________________________________

Position   __________________________________

Have you ever been employed with UTHSC-H? ______ Yes              ______ No

If Yes, please indicate:

Employment Dates      From _______      To _________

Department    __________________________________
Position   __________________________________

 Have you ever been convicted of a criminal offense other than minor traffic violations?
________ Yes ________ No

 If yes, please explain. A criminal conviction will be considered only in relation to the
volunteer service for which you are applying. Seriousness and nature of the offense, time
elapsed, and rehabilitation will be taken into account.

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Education: Please list highest education level attained and any specific areas of expertise.

_______________________________________________________________________

Language Fluency: Are you fluent in any foreign language?       _____ Yes _____ No



If yes, please list languages: Read Write
______________________ ____ ____
______________________ ____ ____

Work Experience: Please list your work experience



Dates employed   Employer                     Position
_____________    _____________________        _________________________________
_____________    _____________________        _________________________________
_____________    _____________________        _________________________________

Areas of Interest: Please list any specific areas in which you would like to volunteer

 _______________________________________________________________________
________________________________________________________________________

 _______________________________________________________________________
________________________________________________________________________
 _______________________________________________________________________
________________________________________________________________________

Dates you are available to volunteer:    From ______________         To ______________

 Approximately when and how many hours per week would you like to volunteer?
__________

I certify that all statements made in this application are true. I understand and agree that
my acceptance as a volunteer is contingent upon a satisfactory security sensitive check.

I also agree that if I am accepted as a volunteer, I will abide by all regulations of the
university. I also agree and acknowledge that the university owns any and all intellectual
property created by me while serving as a volunteer at the university and that I will keep
confidential any and all information or data that I acquire while serving as a volunteer at
the university.




______________________________________ ________________
Signature or prospective volunteer     Date
Created 3/02

				
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