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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.
Application Date:
*
+
Date Available:
*
+
Personal Information
Last Name:
*
First Name:
*
Middle:
Phone/Cell
*
Email:
*
Address
City
State (ABV)
Zip
How did you hear about this position?
Has someone close to you died in last 12 mo.?
Yes
No
Are you currently employed
Yes
No
Is someone close to you terminally ill at this time?
Yes
No
May we contact your present employer?
Yes
No
Can you travel if the job requires it?
Yes
No
How many hours per week are you available to volunteer?
3
8
16
24+
Any preferred days or hours?
Mon:
Tue:
Wed:
Thu:
Fri:
Sat:
Sun:
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:
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?
Yes
No
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?
Yes
No
If yes, please explain:
REFERENCES
Please list two (2) individuals to provide letters of character reference (other than relatives):
Name: (Reference one)
Address with zip
Phone:
Name: (Reference two)
Address with zip
Phone:
AREAS OF VOLUNTEER INTEREST
Administrative Support:
Answering the phone
Serving as a receptionist
Clerical duties (Typing, filing, duplicating, mailings)
Running errands (for supplies, etc)
Community Education:
Speaker (Inform community about hospice philosophy, etc)
Solicit community involvement (volunteers, donations)
Fundraising
Direct Patient Contact
Visit Patient
Family relief (sitting)
Household chores
Run errands (groceries, etc)
Child care support
Flower delivery
Transportation
Bereavement follow-up