DRTC Service Learning Application

Application for Service Learning (Volunteer, Practicum, Internship) opportunities. To apply for DRTC's employment opportunities, visit https://www.drtc.org/apply-now/

2501 N. Utah Ave.

Oklahoma City, OK 73107

405-946-4489 or 405-946-1079

Video phone: (405) 445-7314

www.drtc.org

Applicant Information

Date * +

First Name *

Middle Name

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number * 🛈

Email Address

Referral Source

School Name

Area of Study, if applicable

Total number of required hours, if applicable

Days available (select all that apply) *

Time of day interested (select all that apply) *

Morning

Afternoon

All day

Specific time(s):

Emergency Contact Information

Emergency Contact Person (first and last name) *

Phone Number *

Criminal Background Check Information

A criminal records search is conducted on all volunteer applicants.

Have you ever been convicted, received probation, pleaded guilty, or no contest to any felonies or misdemeanors? *

Yes

No

If yes, describe what, when, where, and the final outcome of the case. *

Have you ever had a confirmation of abuse, neglect, or exploitation made against you? *

Yes

No

If yes, state when, where and explain. *

Save & Return

Save your progress and complete this form later. (optional)

DRTC Service Learning Application

Background Check Authorization and Release

As part of its service learning screening and selection procedure, DRTC requires a background check be conducted. The objective is to verify information provided and to identify any factors that might be inconsistent with DRTC mission. By signing or typing my name below, I give DRTC and/or its designee permission and authority to conduct a background check. I understand and consent to an investigation of any possible criminal records, and other information contained in public records.

Digital Signature *

clear

Date * +

First Name *

Middle Name

Last Name *

Maiden Name

Former Last Names

Date of Birth * +

Driver's License/State ID Number *

Issuing State of Driver's License/State ID *

Expiration Date * +