Volunteer Application Form

Volunteer Application Form
Name*

First NameLast Name
E-mail*
Cell/Primary Phone Number*
Best Time to Call
Secondary Phone Number
Best Time to Call
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Gender*
Are You A Minor?*

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Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Relationship To You*

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Volunteer Terms & Hold Harmless Agreement

Philos Hospitality, Inc. d/b/a Hospitality House of Tulsa

I certify that the information contained in this application is correct to the best of my knowledge. If necessary/applicable, I consent to allow any references to respond to a verbal or written request for information. I also consent for a background check to be completed.

I understand that as a volunteer at Hospitality House of Tulsa I will learn about guests’ private, medical crises and that the information I learn through prayer cards, conversations with guests or staff, and/or learn by being around HHT is to be kept confidential. I promise that I will not share guest names, locations, or medical issues with anyone as this could result in unintended detrimental consequences to HHT guests and/or their families.

I also authorize The Hospitality House of Tulsa, Inc. (HHT) to photograph me while volunteering at HHT and to post my photograph and/or written comments I provide to HHT on HHT’s website, newsletter, or other written or electronic media, for the purpose of promoting HHT.

I, the undersigned, intend to provide volunteer services to Hospitality House of Tulsa. I understand that I will not be entitled to any payment, compensation, or remuneration for my services.

Physical activities which I may be asked to provide include, but are not limited to, walking on uneven and inclined outdoor surfaces, lifting up to 25 pounds, standing for up to two and one half hours without a break, providing physical assistance to guests, construction, remodeling, and working in warm summer
conditions (high temperatures and humidity). I personally assume all risks associated with these activities.

I hereby represent that I am adequately physically conditioned to perform the volunteer services and that I have no physical restrictions which would prohibit my participation in the volunteer activity. I understand that it is my responsibility to avoid an assignment if I feel that performing the activity would put my health at risk. Further, it is my responsibility to inform the volunteer coordinator, his/her assistant, or a manager if I feel I cannot complete my volunteer duty due to any health or safety issue.

On behalf of myself and my heirs, I hereby agree to indemnify, release, and hold harmless the Philos Hospitality, Inc, d/b/a Hospitality House of Tulsa and its directors, officers, employees, volunteers, and agents (collectively, “HHT”) from and against any and all liability for damage to my personal property or physical injury which I experience as a direct or indirect result of (1) providing the volunteer services or (2) HHT’s negligence.

I understand that HHT does not provide any medical or hospital insurance coverage for me, and I acknowledge I have adequate medical and hospital insurance for any injuries that I may incur as a result of my participation as a volunteer.

By entering your name and signature below, you are agreeing to all of the terms in their entirety as stated on this form in the preceeding paragraphs above.
Full Name*

First NameMiddle NameLast Name
Date

MonthDayYear
Date
E-Signature*

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Using your computer mouse or finger (for touchscreen devices) sign your name on the line above.

Volunteer Background Check Request Form

From: Philos Hospitality, Inc. d/b/a Hospitality House of Tulsa

To: VerHoef Information Sources, LLC

19606 E. 37th St. S., Broken Arrow, OK 74014 | (918) 286-3344 | jjvisllc@outlook.com
Requested By: Hospitality House of Tulsa
Date of Request

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
DOB
Social Security Number*
Maiden or AKA Name(s)*
Please complete if you have a maiden or AKA name to be checked. Indicate all names to check. If not applicable, type n/a in the box above.
List places of residence for the past seven (7) years, begining with the most recent. It is important to list the zip code and exact name of the city you reside(d) in.
Address 1 *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Address 1 Dates of Residence*
Example: August 2009-Present
Address 2

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Address 2 Dates of Residence
Example: September 2006-August 2009
Address 3

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Address 3 Dates of Residence
Example: September 2006-August 2009
Address 4

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Address 4 Dates of Residence
Example: September 2006-August 2009
Address 5

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Address 5 Dates of Residence
Example: September 2006-August 2009
In connection with my application for volunteering (including contract for services) with you, I understand that investigative background inquiries are to be made on myself including Motor Vehicle Check, Credit Check, Criminal Felony, Misdemeanor convictions reports in not only the addresses listed above but any other residence where I may have lived. These reports will include information as to my character, work habits, performance and experience along with reasons for termination of past employment from previous employers. Further, I understand that you will be requesting information from various Federal, State, and other agencies which maintain records concerning my past activities relating to any criminal experiences.

I authorize without reservation, any party or agency contacted by this employer to furnish the above-mentioned information. I hereby consent to your obtaining the above information from Information Searches, Inc. and or any of their licensed agents. I understand to aid in the proper identification of my file or records the following information, as well as other information, is necessary.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Applicant's e-Signature

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Should be Empty:

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Volunteer Application Form

Requested By: Hospitality House of Tulsa