Harbor Hospice Volunteer Application
The information on this form will enable Harbor Hospice to use your particular abilities to the fullest extent. Your cooperation in completing it is most appreciated.
How did you hear about this position?
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?
List your Church, clubs, and organizations with which you are involved:
Hobbies, special interests, skills or foreign languages:
Work Skills: List your relevant work experience (professional and volunteer) and personal strengths that you would bring to the position for which you are applying:
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?
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?
If yes, please explain:
Please list two (2) individuals to provide letters of character reference (other than relatives):
Name: (Reference one)
Address with zip
Name: (Reference two)
Address with zip
AREAS OF VOLUNTEER INTEREST
Answering the phone
Serving as a receptionist
Clerical duties (Typing, filing, duplicating, mailings)
Running errands (for supplies, etc)
Speaker (Inform community about hospice philosophy, etc)
Solicit community involvement (volunteers, donations)
Direct Patient Contact
Family relief (sitting)
Run errands (groceries, etc)
Child care support