Your consent for a criminal background check is required along with your social security number. You will give your social security number in person; please do not include it anywhere in this application. Thank you.

AUTHORIZATION FOR RELEASE OF INFORMATION TO: Medical City Dallas

Pursuant to the requirements of the Fair Credit Reporting Act, notice is given that a consumer report may be made in connection with your application for volunteering at Medical City Dallas.The report may include, but is not limited to, information concerning past work history, criminal record(s), plea bargains, deferred adjudications, exclusions from Medicare/Medicaid, GSA sanctions, educational achievement, professional licensure(s) or certification(s), driving record, credit history and past residences. This information will be used, in part, to determine your eligibility for employment or volunteer position within this organization. As long as you remain a volunteer here, the criminal history records check may be repeated at any time.

If you are denied employment or volunteer position, either wholly or partly, because of information contained in this consumer report, a disclosure will be made to you of the name and address of the consumer reporting agency making such report.

I understand the above notice and realize that my offer of a volunteer position is contingent on successful completion of references, license and academic verification, pre-placement health screening for essential functions of the job and the drug screen.

I was recently interviewed and/or am applying for a volunteer position by Medical City Dallas. As part of my volunteer position or potential volunteer position, I authorize you to release my academic records, employment records, and other related background information to Group One services on behalf of Medical City Dallas. I hereby state that all information given by me on this form is true in all respects. I agree that if I am accepted to a volunteer position and the information is found to be false in any respect, I will be subject to dismissal at any time.

I hereby release any individual or entity, including record custodians from all liability for damages of any kind or nature that may at any time result to me because of compliance, or any attempt to comply, with the objectives of this authorization.

I certify that the information provided by me in my volunteer application is true, correct, and complete to the best of my knowledge. I understand that my placement as a volunteer is contingent upon satisfactory references and/or results of a criminal background investigation conducted by a consumer-reporting agency.

I understand I am applying to be a volunteer, not a paid employee at Medical City Dallas. I understand that I am authorized solely to perform tasks assigned specifically to me. I agree to accept full responsibility and to hold harmless Medical City Dallas, its employees, directors, officers, trustees, or agents from any and all claims and damages that may arise from my participation in the volunteer program.

I have read and understand the above and agree to comply with all rules and regulations of Medical City Dallas and the Volunteer Services Department. I understand that failure to comply with such rules and regulations may be cause for my removal from Medical City Dallas volunteer program. Medical City Dallas reserves the right to make changes in all policies and procedures from time to time and, as may be required, changes in operations. I understand Medical City Dallas may terminate my volunteer services for any or no reason.

Please type your name and today's date into the respective fields to acknowledge the above statement.