Hospice Volunteer Application

The information on this form will enable us to use your particular abilities to the fullest extent. Your cooperation in completing it is most appreciated.

Personal Information

Has someone close to you died in last 12 mo.?
Are you currently employed
Is someone close to you terminally ill at this time?
May we contact your present employer?
Can you travel if the job requires it?
How many hours per week are you available to volunteer?
Any preferred days or hours?
STIPULATIONS: Auto Insurance: Proof of personal automobile liability insurance in the minimum amount for the state is required in the form of a Certificate of Insurance. This is a requirment to be able to drive as part of your hospice work.
Do you meet this requirement?
HEALTH STATEMENT: If you are given a volunteer position you will need to provide a health statement to insure that you are free of any communicable diseases. You can request this statement from your physician.
CRIMINAL HISTORY CHECK: There are certain convictions which bar employment and volunteering for health care services. We are required by law to perform a criminal history check.
Have you ever been convicted of a felony?


Please list two (2) individuals to provide letters of character reference (other than relatives):


Administrative Support:
Community Education:
Direct Patient Contact