VOLUNTEER FORM

Your intrest in volunteering is appreciated. Take a few minitues to fill out the form below. We will respond as soon as possible regarding your application.

"*" indicates required fields

At which location are you interested in volunteering?*

Volunteer Information

First Name*

First

Last Name

Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Home Phone

Work Phone

Cell Phone*

Emergency Contact

First Name*

First

Last Name

Last

Relationship*

Emergency Contact Phone*

Primary Physician*

Primary Physician Phone*

Background

Do you have any medical problem, injury, physical limitations, chronic ailment, or other condition that could affect your ability to perform volunteer work?*

Yes

No

Have you ever tested positive for tuberculosis?*

Yes

No

Have you ever been convicted of a felony?*

Yes

No

Have you ever volunteered for a hospice before?*

Yes

No

If so, where?

Have you experienced a personal loss in the past year?*

Yes

No

Are you a veteran?*

Yes

No

If so, which branch of service?

T-Shirt Size*

Are you wanting to volunteer as a requirement for school?*

Yes

No

If so, how many hours does your school require?

Availability

When are you available?*

Days

Evenings

Weekdays

Weekends

What days are you available?*

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Are you available on short notice for temporary assignments?*

Yes

No

Employment / Interests / Skills

Are you currently employed?*

Yes

No

Retired

Employer

Position

Do you drive and have a valid driver's license?*

Yes

No

Do you have auto insurance?*

Yes

No

Do you speak another language?*

Yes

No

Please list any educational background, hobbies, skills, and special interests (office, arts, crafts, etc.) that you feel could be helpful to your volunteer experience*

Why do you wish to be involved in hospice?*

Areas of Interest*

Patient / Family Care

Certified Pet Therapy

Office Support

Sewing / Craft Team

Bereavement Phone Team

Speakers Bureau

Special Events

Other

Special Services

Massage Therapy

Music Therapy

Art Therapy

Hair Stylist

Lawn Care

Light Carpentry

Other

Is there any segment of the population that you would have difficulty serving?*

Yes

No

If so, which population?

Would you mind being around children?*

Yes

No

Would you mind being around animals?*

Yes

No

Would you mind being around smokers?*

Yes

No

Reference 1

First Name*

First

Last Name*

Last

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Reference 2

First Name*

First

Last Name*

Last

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Reference 3

First Name*

First

Last Name*

Last

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Consent

Confirmation*

I hereby confirm that the above information has been field out to the best of my ability and correct to my knowledge.

Name*

First Last

Date*

Parent / Guardian Confirmation*

I am over 18 years of age.

I am under 18 years of age, and I herby confirm that the person below is my parent or guardian.

Name Of Guardian*

First Last

Date*

NAVIGATION

RESOURCES

SERVING FAMILIES SINCE