UTHealth Harris County Psychiatric Center

Student Volunteer Application

Contact Information
(*)denotes required information.

Education/Training



Volunteer Information



  • I am required to report volunteer time to an agency/school/group:


  • I would like to volunteer with:



  • Have you been a patient at UTHCPC?


    Emergency Contact Information
  • In Case of Emergency Notify:

    Consent for volunteers under 18 years of age
  • Are you under 18 years of age? If, Yes please select "Yes" and complete this section. If, No, please select "No" and move to next section.







  •  years of age and is in     grade in school, to serve as a junior volunteer at The University of Texas Harris County Psychiatric Center.

  • I am the:


    Criminal Background Disclosure and Release of Application Agreement
  • A Criminal Background Check must be completed and passed before you can volunteer at UTHCPC.

    I understand that these investigative background inquires may include criminal, driving, prior employment and other reports. Further, I understand that The University of Texas Harris County Psychiatric Center and The University of Texas (UT) Police may be requesting information from various federal, state or other agencies which maintain records concerning my past activities in relations to my driving, criminal, civil and other experiences.

    I hereby authorize, without reservation, any party or agency contacted by The University of Texas Harris County Psychiatric Center and/or The University of Texas Police Department or any other police agency to furnish the above-mentioned information.

    I further release all agents and employees of The University of Texas Harris County Psychiatric Center, the person/persons of such police agencies or departments from all liability resulting from the furnishing of this information to The University of Texas Harris County Psychiatric Center. I further understand that all information received will be kept confidential. Only The University of Texas Police Department, The University of Texas Harris County Psychiatric center and the Department of Public Safety (DPS) will have access to the files, and neither I, nor any other individual except by court order, will be allowed to see the information in these files for any reason.

    I understand the information obtained will be used for acceptance or denial for the volunteer program. I, also understand that if after review of this information, the UT Police, HCPC or DPS determines that I represent a risk to the institution, I will be deemed unsuitable for a volunteer position and will be separated or removed from consideration.

    The authorization granted herein expires one year from the date hereof. I have read and understand the above information, and assert that all information provided by me is true and accurate, including my identity.


  • Do you have a Social Security Number?
  • Do you have a Driver's License?