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HAYDEL MEMORIAL HOSPICE
VOLUNTEER APPLICATION

Name of Applicant
Birth date
Address
City
Zip
Home Phone
Work Phone
Employer
Occupation
Can you receive calls at work     Yes     No     Emergency Only
Person to be notified in an emergency:
Name
Phone
Address
City
Zip
Education/Special Training
Work Experience
Two Personal References (excluding family members). Please provide a complete address, as reference are verified by mail.
Name
Phone
Address
City
Zip
Name
Phone
Address
City
Zip
Identified Areas of Interest: (non-patient does not require 30 hour education course)
Patient/Family Care
In Home   In Nursing Home   In Facility   Transportation   Personal Care   Meal Delivery   Alternative Therapies  
Bereavement
Caller   Home Visits   Support Group Co-Facilitator   Transportation   Office/Clerical   Memorial Service Committee
Non-Patient Services
Clerical   Fundraismg   Mailings   Events   Marketing   Courier   Switchboard   Data Entry
Do you know a language other than English?     Yes     No
language
Speak   Read   Write
language
Speak   Read   Write
Other special services: (manicurist. hairdresser, masseuse, etc.)
Do you have access to transportation?     Yes     No
How did you hear about our Hospice Volunteer program?
Why do you want to be a hospice volunteer?
What qualities (skills, talents, knowledge, and experiences) do you feel you can incorporate into you hospice volunteer work?
Death and Dying
What are your thoughts and feelings about death?
Have you ever been with someone at the time of their death?    Yes     No
If yes, please describe briefly:
Have you ever provided care to anyone who was dying?     Yes     No         (If yes, please explain)
When thinking of your own death, what words best describe death to you?
I do not think about my own death   sorrowful   natural   frightening   painful   lonely   joyful
heavy   peaceful   dark   other
Comments
CODE OF ETHICS FOR VOLUNTEERS
As a volunteer, I realize that I am subject to a code of ethics similar to that which binds the professional in the field in which I work. I, like them, assume certain responsibilities and expect to account for what I do in terms of what is expected of me.

I understand that any information that is disclosed to me while assisting the Hospice is confidential.

I interpret "volunteer" to mean that I have agreed to work without compensation in money. Having been accepted as a volunteer worker, I expect to do my work according to the standards set forth in the Volunteer Policies and Procedures.
DECLARATION
I hereby certify that the statements made on this application are true and correct to the best ofmy knowledge. l understand that, by submitting this application, I authorize inquiries to be made concerning my employment, character and public records for the purpose of determining my suitability as a volunteer. I affirm that I have read the volunteer Code of Ethics and agree to abide by its regulations. I agree to respect the confidentiality of any client information I acquire in the course of my volunteer activities with Hospice.

Applicant Signature
Date