Volunteer Profile

Cox South
3801 S. National
Springfield, MO 65807
417-269-4169

Meyer Orthopedic and Rehabilitation Hospital
1000 E. Walnut Lawn
Springfield, MO 65807
417-269-3169

Cox North
1423 N. Jefferson
Springfield, MO 65802
417-269-3169

Cox Monett
801 Lincoln Ave.
Monett, MO 65708
417-354-1409

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Last Name  

First Name

Middle Name

Home Phone

Cell Phone

Address

City

Zip

Email (if checked regularly)  

Place of Employment

Work Phone

 

 

Have you been employed by CoxHealth?

Have you been a CoxHealth Volunteer before?

Have you entered a plea of guilty, no contest,nolo contendere, or otherwise been convicted of a criminal act involving controlled substances?

Have you entered a plea of guilty, no contest,nolo contendere, adjudication of guilt (SIS), or otherwise been convicted of a felony or a misdeanor (including but not limited to such offenses as DUI, battery, theft, writing worthless checks, suspended license, etc.)?

Are you attending school or planning to enroll?

   If Yes list school:

Education/Special Training/Skills/Hobbies:

Is there a specific area or Hospital you would like to work?

Is there any area you prefer not to work?

When are you able to volunteer?

How many hours a week would you like to volunteer?

How did you learn about our volunteer program?

List previous volunteer experience:

Why do you want to be a volunteer?

Why did you choose CoxHealth?

 

 


Person to contact in case of emergency:

Name

Telephone

Relationship

Place of Employment

 

I understand that effective November 21, 2013, CoxHealth and its Affiliates will no longer place individuals for volunteer service who use tobacco products. By submitting this Application for Volunteering, I represent and agree (1) if placed after November 21, 2013 CoxHealth will not accept me as a volunteer if I am a tobacco user or test positive for nicotine use, (2) CoxHealth pre-placement procedures include urine screening for nicotine use, (3) if an offer of volunteer placement has been extended, CoxHealth will withdraw the offer if I am in violation of this policy, and (4) if placed in volunteer service by the CoxHealth after November 21, 2013, I will not during my volunteering use any tobacco product. I understand that use of a tobacco product during my volunteer service with the System is grounds for corrective action which may include immediate termination of volunteer placement.

Date and Time: 4/18/2014 11:49:19 PM