The Center for Hospice and Palliative Care, Inc.
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News and Events - Volunteer Application Form

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BEACON
Name:
Address:
Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Email:
 
I would like to receive the Center for Hospice e-newsletter.
 
May we contact you at work
Yes:
No:
   
Emergency Contact:
Phone:
Relationship:
   
Do you have a valid driver's license/current auto insurance and car for use as a volunteer?
Yes:
No:
   
Volunteer Position Desired:
Patient Care:
Bereavement Phone Caller:
Office:
Community Relations:
Fund Raiser:
Complimentary Techniques:
Speaker's Bureau:
Intern(indicate field desired):
Group Project:
List Specialty (such as interpreter, licensed hair dresser, pet therapy):
 
Volunteer History Experience:(list most recent)
Agency:
Assignment:
Length of Service:
   
Agency:
Assignment:
Length of Service:
   
Work History: (List most recent, if retired, list past occupation)
Name:
Address:
Dates:
Occupation/Position:
   
Name:
Address:
Dates:
Occupation/Position:
   
Are you currently employed?
Yes:
No:
   
Do you have any physical conditions, health problems, or allergies which we should consider before placing you as a volunteer?
 
   
Special skills, interests, hobbies:
 
   
Education:  
High School:
Last Year Completed:
Degree Completed:
   
College:
Last Year Completed:
Degree Completed:
   
Trade, Business School:
Last Year Completed:
Degree Completed:
   
Current Student?  
Yes:
No:
School:
   
References: Please list two persons other than family members who have know you for at least one year:
Name:
Address:
Daytime Phone:
Emai:
Association:
Years Acquainted:
   
Name:
Address:
Daytime Phone:
Email:
Association:
Years Acquainted:
   
I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for refusal to be considered for volunteer placement.
Yes:
No:
   
I authorize the Center for Hospice & Palliative Care, Inc. to contact the above references.
Yes:
No:
   
 
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111 Sunnybrook Court
South Bend, IN 46637
574-243-3100
800-413-9083 		112 South Center Street, Suite C
Plymouth, IN 46563
574-935-4511
800-774-2784
2901 East Bristol Street, Suite C
Elkhart, IN 46514
574-264-3321
866-264-3321		 Life Transition Center
215 Red Coach Drive
Mishawaka, IN 46545
574-255-1064