Form 8653

Print Blank Form

Volunteer and Community Engagement

Volunteer/Intern Application

Thank you for your interest in volunteering with the Texas Health and Human Services Commission (HHSC)

Services

Select Type of Service*

I'm volunteering as

Group Fields

Type of Group(Hold the Ctrl key to select more than one)

Organization Name

Other organization type

Number of Members in my Group

Individual Fields

Frequency of volunteering

How did you hear about us?(Hold the Ctrl key to select more than one)

Name of website

Name of School or University

Explain if 'Other' is selected

Are you a current HHS employee?

Current Work Site*

Current Assignment*

Supervisor's Name*

Supervisor's Phone*

Have you been designated in the Nurse Aide Registry or Employee Misconduct Registry as having abused, neglected or exploited a resident or consumer?*

Intern Fields

Are you receiving class credits for this assignment?

Institution/School

Department Name

Teacher/Professor Name

Internship field of study

Internship Supervisor Required?

Internship placement requirements

General Information

Please provide your contact information (*= Required Field):

Last Name*

First Name*

Middle Initial

Home Area Code and Telephone #*

Work Area Code and Telephone #

Cellular Area Code and Telephone #

List all names you have ever used

I affirm that every name I have ever used is listed above.

Address

City

County

State

Zip

Date of Birth*[ 4/19/2024 ]

Sex

Email Address*

Current Employer

Employer Address

Employer Phone #

Have you been convicted of any type of criminal offense?

Judicial Court Assignment

Which Court

Number of Hours Required by Court

Deadline[ 4/19/2024 ]

Probation Officer's Name

Area Code and Telephone #

Emergency Contact

Name

Relationship

Day Telephone #

Evening Telephone #

Placement

Select Placement Type*

Select State Hospital

Select State Supported Living Center

Providing Transportation for Residents - Are you willing to transport residents/others?

An examination of your driving history record will be made before you are allowed to transport residents/others and HHS will determine whether you are allowed to do so. Proof of current minimum liability coverage required by the State of Texas, a certificate for a defensive driving course taken within the past three years and a copy of the current Texas driver’s license must be provided.

Security Statement - Are you currently employed or have you ever been employed at HHS, DSHS, a State Hospital, Community Center, Legacy DADS, Legacy TDMHMR or ICF/ID (State Supported Living Center)?

Texas Health and Human Service (HHS) conducts a criminal background check, Client Abuse and Neglect Reporting System check, a Nurse Aide Registry check and an Employee Misconduct Registry check on each volunteer applicant. HHS is required to conduct finger print criminal history background check on volunteers who will have direct contact with residents. If your criminal history record indicates that you have been convicted of any criminal offense or granted deferred adjudication or other type of pretrial diversion that would cause FAFS to deny placement, the placement will not be made. With a few exceptions, you have the right to request and be informed about the information that the HHS obtains about you. You are entitled to receive and review the information upon request. You also have the right to ask HHS to correct information that is determined to be incorrect. (Government Code, Sections 552.021, 552.023, 559.004).

Date[ 4/19/2024 ]

Signature

Interest/Background

Have you volunteered with a State Agency before?

Are you bilingual?

Explain if 'Have you volunteered with a State Agency before?' is 'Yes'

Enter languages if 'Are you bilingual?' is 'Yes'

Please share skills and interests you would like to use

Date available to start[ 4/19/2024 ]

Select the Days and Times you would like to volunteer(Hold the Ctrl key to select more than one)

Assignment Preference(Hold the Ctrl key to select more than one)

Explain if 'Assignment Preference' is 'Other'

Notes/Accommodations

Confidentiality Statement - I agree to respect the confidential nature of all personal contact with individuals served by HHS and adhere to all laws, rules, policies and procedures pertaining to confidentiality regarding all records, files and identifying information of individuals, former or potential with whom I come into contact as a volunteer. I understand violation of this confidentiality requirement can result in immediate dismissal from my volunteer assignment.

Affirmation - By my signature, I adhere to all departmental rules, policies and procedures pertaining to my volunteer placement. Access to a copy of the Volunteer Procedure Manual will be provided to me during orientation. I understand that I must complete all required orientation and placement-specific training outline by the Volunteer Assignment Description. I affirm that the information on this application is accurate to the best of my knowledge.

Date[ 4/19/2024 ]

Signature*

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