The Center for Hospice and Palliative Care: Types of Volunteers

Volunteer Application Form

Name:

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:

Email:

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:

For verification purposes, please answer the following question: What is two plus three?

(Example: nine)

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