(If you are under 18 please contact Volunteer
Services to request a Jr. Application)
Preferred Assignment (if known):
Please indicate times you are available to volunteer by placing a check in applicable
Have you ever been convicted of a crime or recieved deferred adjudication (other
than a traffic violation)?
If "yes", please state offense, date and location (A conviction record will not
necessarily be cause of disqualification):
Are you currently an employee with JPS Health Network?
If "Yes", list Department and Position
Date of last TB screening (if known):