Volunteer Form

Volunteer Application

Please fill out the electronic application below to volunteer in San Antonio, Harlingen, and Brownsville. Fields with an asterisk(*) are required.

DATE: *

First Name: *

Last Name: *

Preferred Name: *

Street Address: *

City: *

State: *

Zip: *

Mobile Phone: *

Other Phone: *

EMAIL: *

Best way to contact you?

Are you over the age of 18?

Are you currently employed?

If yes, name of employer:

Position:

Volunteer experience:

Education:

Areas of interest:

Special skills:

Languages other than English:

Volunteering for school credit?

Why do you want to volunteer?

How did you hear about us?

Days and times available:

PREFERENCE OF VOLUNTEER ACTIVITY:

If other:

Professional / Personal References

1. Name: *

PHONE: *

Email:

WHAT IS YOUR RELATIONSHIP TO THIS REFERENCE?

2. Name *

PHONE: *

Email:

WHAT IS YOUR RELATIONSHIP TO THIS REFERENCE?

Emergency Contacts

1. Name:

PHONE:

Relationship:

2. Name:

PHONE:

Relationship:

Criminal Background

Have you ever been arrested?

Have you ever been convicted of a misdemeanor or felony crime?

Have you ever been subjected to deferred adjudication on a misdemeanor or felony crime?

If your answer is “Yes” to any of the above questions, please explain in concise detail, giving dates and nature of offense, name and location of court, and disposition of the case(s).

Please note that an arrest, conviction of a crime or subjection to deferred adjudication may not disqualify you from consideration for volunteer service, but a false statement or dishonest response will disqualify you.

I agree *

I have read the Volunteer Agreement below and I understand that by selecting "I agree" this constitutes a legal signature confirming that I acknowledge and agree to this Applicant Authorization & Release Statement.

VOLUNTEER AGREEMENT

I certify that all information provided on this application is true, correct and complete. I understand that omission or falsification of information is grounds for refusal of my volunteer service or for my dismissal from volunteer service upon discovery. I authorize Planned Parenthood South Texas, and any of its subsidiaries, (Planned Parenthood Cameron County, Planned Parenthood San Antonio, Planned Parenthood South Texas Physician’s Group, Planned Parenthood South Texas Surgical Center) to verify all of the information contained in this application and consent to communications with individuals and companies to verify this data and obtain other information / references / background checks on my suitability as a volunteer. I release Planned Parenthood South Texas, and any of its subsidiaries, (Planned Parenthood Cameron County, Planned Parenthood San Antonio, Planned Parenthood South Texas Physician’s Group, Planned Parenthood South Texas Surgical Center) and any individuals / companies confirming data and providing information about me from any claim or liability.

I agree to comply with Planned Parenthood South Texas’ rules and regulations. I agree to respect the confidentiality of all patient/client/donor information which I gain either directly or indirectly in my work. I understand that Planned Parenthood South Texas is an agency of inclusion – with equality and respect given to all individuals, regardless of their age, color, religion, disability, gender, gender identity, national origin, physical characteristics, race and ethnicity, sexual orientation, marital status or socioeconomic status. Planned Parenthood South Texas embraces diversity and appreciates the differences each individual brings to the agency. I understand that discrimination of any kind will not be tolerated. I understand that any breach of this agreement constitutes grounds for immediate dismissal.