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Volunteer Application
Applicant Information
Name
Phone
Daytime Phone
Current address
City
Zip code
State
Email address
Is the volunteer 18 years or older?
Date of Birth
If under 18, will the volunteer be exposed to Research and Clinical Laboratories? If yes, describe nature of exposure.
(Minors under the age of 18 are prohibited from working with BSL-2 Agents, radioactive material, acutely toxic
agents or chemicals deemed hazardous by Environmental Health, Safety and Risk Management.)
Is the volunteer currently a student?
Is the volunteer currently employed?
If UT Tyler, please provide UT Tyler EID #
If yes, do they have clearance from immigration services?
Service Information
Anticipated length of volunteer service
Start Date
End Date
Anticipated hours per week
Location
Sponsoring UT Tyler Department
Sponsoring Manager Name
Relationship to Sponsoring Manager
If other, please explain.
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Describe the volunteer activity (be specific).
Will the volunteer be exposed to hazardous materials or conditions? (i.e., blood, chemicals, industrial tools, extreme
temperatures, sharp objects, stored energy, etc.) If yes, please explain.
Emergency Contact
Name
Relationship
Phone
Name
Relationship
Phone
Education
School Name
Location
Enrollment Status
Degree Received
Reference(s)
Name
Phone #
Email
Relationship
________________________________________ __________________________
Signature of Requestor Date
I certify to the best of my knowledge that the information in this application is complete and accurate.
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Release and Indemnification Agreement for Volunteers
I, ____________________________ the above named applicant, am 18 years of age, or older and am
voluntarily performing service for the Institution of my own free will and without any promise of
remuneration, compensation, or benefits, including insurance. If under 18 years of age, I have obtained
parental consent. I acknowledge that within the course and scope of my activities as a volunteer, I may be
exposed to hazards or risks that may result in my illness, personal injury, or death and I understand and
appreciate the nature of such hazards and risks.
In consideration of being permitted to participate in the Activity, I hereby accept all risk to my health and of
my injury or death that may occur while I am acting within the course and scope of my activities as a
volunteer.
I hereby release the above named Institution, its governing board (The University of Texas System Board of
Regents), officers, employees and representatives, in their individual and official capacities, from any
liability to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and
causes of action for loss of or damage to my property and for any and all illness or injury to my person,
including my death, that may result from or occur during my activities as a volunteer, WHETHER CAUSED BY
NEGLIGENCE OF THE INSTITUTION, ITS GOVERNING BOARD, OFFICERS, EMPLOYEES, OR REPRESENTATIVES,
OR OTHERWISE.
I further agree to indemnify and hold harmless the above-named Institution and its governing board (The
University of Texas Board of Regents), officers, employees, and representatives, in their individual and official
capacities, from liability for the injury or death of any person(s) and damage to property that may result from
my negligent or intentional act or omission while acting as a volunteer.
I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND
CAUSES OF ACTION FOR MY INJURY OR DEATH OR DAMAGE TO MY PROPERTY THAT OCCURS WHILE
SERVING IN MY CAPACITY AS A VOLUNTEER AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED
FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY
NEGLIGENT OR INTENTIONAL ACT OR OMISSION.
______________________________ _____________________
Signature of Applicant/Parent Date
(If applicant is under the age of 18, signature of parent or legal guardian is needed here.)
______________________________ _____________________
Signature of Supervisor Date
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Please return this form to UT Tyler, Office of Human Resources.
Mandatory Volunteer Certifications
Please initial each statement indicating you read and agree to each provision.
_____I understand that participation is contingent upon successful completion of a criminal background
check. I agree to be subject to a criminal background check.
_____I understand and agree to all terms and conditions of service as set forth in the UT Tyler Volunteer
Policy.
_____I grant and authorize UT Tyler, acting through the University of Texas System, its employees and agents
to make use of, license or assign the use of, my image, appearance, likeness, voice and/or photograph, and
other reproductions of any of these, in still photographs, videotapes, publications, audio, sound recordings,
web sites, electronic and other media and/or motion pictures, (hereinafter all of which are included in the
term “Media”) and to do so with or without mention of my name.
_____I understand and agree that I am to receive no compensation of any kind, monetary or otherwise, on
account of or arising from the production, publication, recording, rebroadcasting, or other use of such Media.
UT Tyler shall have complete ownership of the Media produced or published and shall have the exclusive right
and license to make such use of that Media as it wishes, including, but not limited to the right of performance,
display, reproduction and distribution in all media, and the right to create, perform, display and distribute
derivative works of the Media.
_____I hereby release the University of Texas System, UT Tyler, its employees and agents from all expenses,
claims and liabilities incurred by me arising out of or in connection with my appearance and/or the use of the
Media.
_____As an authorized volunteer I understand that I will be acting on behalf of UT Tyler and I will conduct my
activities accordingly. I have read and agree to the terms and conditions of my activities outlined in all
applicable policies.
_____I will not copy, transcribe, record, or memorize confidential information in any manner, nor disclose or
use such information for any purpose other than for the limited purpose of providing the assigned services
with UT Tyler.
______________________________ _____________________
Signature of Applicant/Parent Date
(If applicant is under the age of 18, signature of parent or legal guardian is needed.)
Please return this form to UT Tyler, Office of Human Resources.
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