Texana - 18+ years old

LAST NAME:
FIRST NAME
MIDDLE INITIAL
DATE OF BIRTH (e.g. mm/dd/yy)
SOCIAL SECURITY NUMBER #*
DRIVER'S LICENSE #
STREET ADDRESS
CITY
STATE
ZIP
SEX:
HOME PHONE
CELL PHONE
WORK PHONE
EDUCATION
- High School
- College
- Other
OCCUPATION
SUPERVISOR
HOW LONG?
HAVE YOU EVER BEEN CONVICTED BY FEDERAL, STATE, OR ANY OTHER LAW ENFORCEMENT AUTHORITIES FOR ANY VIOLATION OF ANY FEDERAL, STATE, OR MUNICIPAL LAW, REGULATION OR ORDINANCE?
- Yes
- No
IF YES, DESCRIBE:

REFERENCES:
Please list two references other than relatives. (one professional, if available) First reference information:
NAME
ADDRESS
PHONE
Second reference information:
NAME
ADDRESS
PHONE
In case of an emergency, please notify:
NAME
ADDRESS
PHONE
All the information on this application is accurate to the best of my knowledge. I understand I will start on a trial basis and agree to take the orientation offered. I understand information regarding the persons I work with is confidential. Texana Center is committed to diversity and inclusiveness, and there shall be no discrimination against an otherwise qualified individual on the basis of race, ethnicity, gender, religion, national origin, socioeconomic status, age, disability or any other basis prohibited by state or local law. Further, I understand that as a volunteer, I am offering my services of my own free will without any expectation of compensation, benefits or insurance of any kind.
*
- I UNDERSTAND
SIGNATURE OF APPLICANT (FIRST AND LAST NAME)

VOLUNTEER CONFIDENTIALITY AGREEMENT

As an volunteer, I understand that I will have access to confidential information, which may include, but is not limited to information related to:

• CLIENT/PATIENTS AND/OR FAMILY MEMBERS: Such as records, conversations, demographic information, financial information, sensitive medical information including HIV/ AIDS status, etc.
• EMPLOYEES, VOLUNTEER, STUDENTS, & CONTRACTORS: Such as salaries, employment records, disciplinary actions, sensitive medical information including HIV/ AIDS status, etc.
• TEXANA CENTER BUSINESS INFORMATION: Such as financial records/reports, internal reports, memos, contracts, presentations, survey results communications, proprietary computer programs and technology, etc. According, as a condition of and in consideration of my access to confidential information, I agree that:

I WILL NOT:

• Exhibit or divulge the content of any confidential record or report except to fulfill a work assignment;
• Attempt to access information by using another person’s user identification code or password;
• Remove any records, reports or copies from their storage location except in the performance of my duties;
• Use Texana resources or information to engage in illegal activities, or harass anyone;
• Allow unauthorized use of information maintained, stored or processed by Texana Center;
• Seek personal benefit of, or permit other to benefit personally by any confidential information available through my work assignment;
• Divulge copy, release, sell, loan, review, alter or destroy any confidential information except as assigned and properly authorized within the scope of my volunteer duties at Texana Center.

I WILL:

• Use confidential information only as needed to perform my legitimate duties as a volunteer with Texana Center;
• Access only confidential information for which I have a need to know;
• Only disclose information to those authorized to receive it;
• Respect the privacy and rules governing the use of any information accessible through paper or electronic (computer system or network) and only utilize information necessary to perform my volunteer assignment;
• Report any violations of privacy/ confidentiality policies;
• Abide by all the policies and procedures established regarding confidential information.
- AS AN VOLUNTEER, I UNDERSTAND THAT I RECOGNIZE AND ACKNOWLEDGE THAT I MAY HAVE ACCESS TO WHAT THIS AGREEMENT REFERS TO AS “CONFIDENTIAL INFORMATION”.
Failure to comply with this agreement may result in denied access to confidential information and could include the dismissal from volunteer duties at Texana Center. Under state and federal laws and regulations, civil or criminal penalties could occur. By signing this, I agree that I have read, understand and will comply with this agreement:
TYPE YOUR FULL NAME:

DPS Computerized Criminal History (CCH) Verification
- I HAVE BEEN NOTIFIED THAT A COMPUTERIZED CRIMINAL HISTORY (CCH) VERIFICATION CHECK WILL BE PERFORMED BY ACCESSING THE TEXAS DEPARTMENT OF PUBLIC SAFETY SECURE WEBSITRE AND WILL BE BASED ON NAME AND DOB INFORMATION I SUPPLY.
Because the name based information is not an exact search and only fingerprint record searches represent true identification to criminal history, the organization (as listed below) conducting the criminal histroy check is not allowed to discuss any information obtained using this method, therefore the agency may offer the opportunity to have a fingerprint search performed to clear any misidentification based on the name search, if the search provides a criminal report I know could not be mine. For the fingerprinting process I will be required to submit a full and complete set of my fingerprints for analysis through the Texas Department of Public Safety AFIS (automated fingerprint identification system). I have been made aware that in order to complete this process I must have the correct fingerprinting (fast) form from this agency, make an online appointment, submit a full and complete set of my fingerprints, and pay a fee of $9.95 to the fingerprinting services company, L1Enrollment Services. Once this process is completed and the agency receives the data from DPS, the information on my fingerprint criminal history record may be discussed with me.
TYPE YOUR FULL NAME:

18+ years

Step 1 of 5

VOLUNTEER PLACEMENT:

YOUR SKILLS:

REFERENCES:

VOLUNTEER CONFIDENTIALITY AGREEMENT

DPS Computerized Criminal History (CCH) Verification

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