We thank you for your interest in becoming an INTEGRIS Volunteer. After completion of the application you will receive an email regarding your next step. We look forward to visiting with you.


Contact Information

* Indicates required field

SS number and Date of Birth are required for Background screening



Referred by: List name of individual or group


Demographic Information

Please provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.



Emergency Contact


Availability

Please indicate the days and times you are usually available to volunteer.



Facility Preference


Interests

What are you interested in doing or willing to do (with training) as a volunteer? Check all that apply



Skills and Experience

Please tell us more about the skills and experience you have.



Background Screening

In connection with my application to volunteer and, if applicable, for the duration of, my volunteer services with INTEGRIS Health, Inc. ("INTEGRIS"), I authorize INTEGRIS to obtain consumer reports that relate to my criminal history through its employees, representatives, agents, and independent contractors. These reports may include information as to my general reputation, character, personal chacteristics, and mode of living. I understand that you may be requesting information from various federal, state, and other agencies or institutions, which maintain public and non-public records concerning my past criminal history. A photo copy or facsimile of this Consent shall be considered as effective and valid as the orginial. I authorize, without reservation, any party, institution, or agency contracted by this employer to furnish the above mentioned information:



Anything else?

Please provide us with any additional information you feel will help us know more about you, or use this space to complete any above references.



Statement

I, the undersigned person, declare that I am not currently required to register under the provisions of the Oklahoma Sex Offenders Act or the Mary Rippy Violent Crime Offenders Registration Act.



Agreement

I agree to submit to examinations which may include appropriate immunizations, chest x-rays and/or laboratory tests which may be necessary as part of my volunteer services. I authorize the person(s) making tests or x-ray films to report the results to the hospital. I realize this information is confidential and may be used to determine my eligibility to volunteer.

I understand and agree that submitting this application form does not automatically register me as an INTEGRIS Health Volunteer, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering.

By submitting this form, I attest that the information I have provided on the form is true and accurate. I understand and agree that falsification of this or any other information is grounds for immediate termination.