Required fields are marked with an asterisk *. Junior Volunteer Registration FormMedical City Fort WorthName *DateEmail address *Birthdate *Address *City *State *Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code *Phone Number *Parent(s) Name(s)Are you employed? Yes NoIf yes to the above, where?Special skills?Hobbies/clubs?Foreign Languages?Have you been convicted of any crimes? Yes NoIf yes, please explain.Do you have previous volunteering experience? Yes NoIf yes, please explain.Why do you wish to volunteer at Medical City Fort Worth?Days preferred? Monday Tuesday Wednesday Thursday FridayFor how many hours?Parent email addressTwo personal references (No Relatives)NamePhoneAddressNamePhoneName of Personal PhysicianPersonal Physician Phone Any illness in the last year? Yes NoIf yes, please explain.Any medications currently being taken? Yes NoIf yes, please list and whyAre you allergic to any drugs? Yes NoIf yes, please list.Do you have any limitations? Yes NoIf yes, please explainIn case of emergency contact and relationship *ICE Home Phone *ICE Work Phone *I UNDERSTAND THAT IN ORDER TO BE A JUNIOR VOLUNTEER I MUST ABIDE BY ALL RULES AND REGULATIONS. I ALSO UNDERSTAND THAT I MUST BE IN FULL UNIFORM EACH AND EVERY DAY I AM VOLUNTEERING OR I WILL BE ASKED TO RETURN HOME AND VOLUNTEER ANOTHER DAY.Signature (type your name) *OPPORTUNITIES FOR VOLUNTEERS ARE PROVIDED WITHOUT REGARD TO RELIGION, CREED, RACE, NATIONAL ORIGIN, AGE, SEX or DISABILITY STATUS TO OTHERWISE QUALIFIED INDIVIDUALS. Rate Your Experience Submit SuccessThe form was successfully sent. There was an error with the form submission.