Volunteer Application - Good Samaritan Health Services

Preferred name

Phone number *

Address *

Birthdate *

Gender *

Have you ever been convicted of a felony? *

How did you hear about this volunteer opportunity? *

Emergency Contact

First and Last Name *

Relationship *

Emergency Contact Phone Number *

Availability

What is your availability to volunteer?

Monday morning 9:00am & 1:00pm-Tulsa Dream Center North

Monday afternoon 12:30pm-4:30pm-Tulsa County Social Services

Monday afternoon 12:00pm-4:30pm-Asbury New Patient Clinic

Monday evening 5:00pm-9:00pm-Asbury Walk In Clinic

Tuesday morning 7:45am-12:00pm-Spirit Life Church Clinic

Tuesday afternoons 1:00pm-4:00pm-Tulsa Dream Center North

First and Third Tuesday evening of every month 5:00pm-9:00pm-Sand Springs Church That Matters Clinic

Second and Fourth Tuesday evening of every month 5:00pm-9:00pm-Asbury Tuesday Clinic

Wednesday mornings 7:30pm-11:30pm-Tulsa Dream Center West

Wednesday mornings 8:30am-12:30pm-Tulsa Dream Center North

Wednesday afternoons 12:00pm-4:30pm-Asbury Wednesday Clinic

Thursday mornings 7:30am-12:00pm-Asbury Thursday Clinic

Thursday afternoons 12:30pm-4:30pm-Asbury Chronic Disease Clinic

First and Third Thursday evenings 4:30pm-8:30pm-Memorial Baptist Clinic

Second and Fourth Thursday evenings 4:30pm-8:30pm-Garnett Road Baptist Church Clinic

First and Third Friday mornings of every month 7:30am-12:30pm-First Baptist Glenpool

Second and Third Friday mornings of every month 7:30am-12:30pm-Asbury Friday Clinic

First and Third Friday afternoons of every month 12:30pm-4:30pm-Asbury Women's Clinic

2nd Saturday of the month 7:30am-1:00pm-Women's Clinic

If wanting to volunteer at a specific Women's Health Clinic church location please indicate below.

Volunteer Opportunities

Please select what opportunities you would be interested in.

Site Coordinator- Responsible for the overall coordination of the clinic site including volunteer schedule and implementing site's vision for transformation in the community.

Check In- Greet Patients, number on appointment list as patients enter clinic, give and explain new patient paperwork and place completed charts in numbered folder for Registration volunteer to process.

Registration-Enter and confirm patients' demographic information is correct, up-to-date and complete in the EMR system.

Vitals-Conduct a medical history review to find out the patients' chief complaint, sign and symptoms, and obtain a set of vital signs to enter into EMR system.

Runner- Greet patients and direct them to each station throughout clinic as well as into the exam room.

Prayer Partner-Pray with patients who would like prayer.

Interpreter-Interpret information for patients as they are processed through the clinic.

Dispensary of Hope Medication calls-call patients from Good Samaritan office to let them know their medication in ready to be picked up at clinic.

Office Help- sort, file data entry etc.

Other

What language can you interpret?

Spanish

Zomi/Burmese

ASL

Non Medical Training

Please describe your professional experience/training.

Medical Professional Training

Are you a medical professional? *

Spiritual Reference

Please chose your pastor, small group leader, Sunday school leader, spiritual mentor or other person in a position of spiritual leadership in your life.

Spiritual Reference Title

Spiritual Reference Name *

Spiritual Reference Phone Number *

Spiritual Reference Email *

Please describe your relationship to spiritual reference and how long you have known this person. *

Personal Reference

Personal Reference Title

Personal Reference Name *

Personal Reference Email *

Personal Reference Phone Number *

Please describe your relationship to your personal reference and how long you have known this person. *

Work or Personal Reference

Work/Personal Reference Title

Work/Personal Reference Name *

Work/Personal Reference Phone *

Work/Personal Reference Email *

Please describe your relationship to work/personal reference and how long you have known this person. *

Spiritual Background

Name of church you attend.

Pastor's name

Do you confess Jesus Christ as your Lord and Savior? *

Yes

No

Briefly describe your relationship with Jesus Christ *

Consent

FOR CHECKS ON ACCURACY, REFERENCES AND BACKGROUND

Your name below is your signature of agreement *

Date

School