Please complete this application form if you are interested in becoming a CoxHealth volunteer. Once you complete the form, click the continue button at the bottom. The information you submit through this online form is protected using Secure Sockets Layer (SSL) technology. This means that your information is encrypted as it travels between your computer and our volunteer database. This is the same technology used by banks to protect online banking services and online merchants to protect credit card information. Once your data reaches our volunteer database, it is protected by hardware firewalls, secure servers, database encryption, and other security measures.


CoxHealth’s Mission is to improve the health of the communities we serve through quality health care, education, and research.





Name and address


Military Service

Answer with a yes or no. Do not leave blank.



Compliance

Answer with a yes or no. Do not leave blank.



Compliance

Answer with a yes or no. Do not leave blank.



Why do you want to volunteer?


Is there an area you would like to volunteer?


Is there an area you would not like to volunteer?


List any previous volunteer experience:


Why did you choose CoxHealth?


Emergency contact

Please complete this section.



I understand

that effective November 21, 2013, CoxHealth and its Affiliates will no longer place individuals for volunteer service or employment 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 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 within the System is grounds for corrective action which may include immediate termination of volunteer placement.


I certify that the answers given by me to the questions on the application to volunteer are true and correct without consequential omissions of any kind whatsoever. If accepted for volunteer service, I agree to abide by rules and policies of CoxHealth. I am aware that a criminal background check will be done as required by Missouri Law. CoxHealth is a Drug Free Work Place and under the Drug Free Work Place Act of 1988. I agree to abide by such established policies as it relates thereto.