Volunteer Form Please Fill Out Our Volunteer Form: Volunteer FormFirst NameLast NameBirthdateAddressAddress Line 1CityStateZip CodeHome PhoneWork PhoneEmployerOccupationCan you receive calls at work? Yes No Emergency OnlyPerson to be notified in an emergency:Emergency Contact's AddressAddress Line 1CityStateZip CodeEducation/Special TrainingWork ExperienceTwo Personal References (excluding family members). Please provide a complete address, as reference are verified by mail.First NameLast NamePhone NumberAddressAddress Line 1CityStateZip CodeFirst NameLast NamePhone NumberAddressAddress Line 1CityStateZip CodeIdentified 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 TherapiesBereavement Caller Home Visits Support Group Co-Facilitator Transportation Office/Clerical Memorial Service Committee Alternative TherapiesNon-Patient Services Clerical Fundraising Mailings Events Marketing Courier Switchboard Data EntryDo you know another language other than English?YesNoLanguages?What do you know about the language? Speak Read WriteOther special services: (manicurist, hairdresser, masseuse, etc.)Do you have access to transportation?- Select -YesNoHow 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 DyingWhat are your thoughts and feelings about death?Have you ever been with someone at the time of their death?- Select -YesNoIf yes, please describe briefly: Have you ever provided care to anyone who was dying?- Select -YesNoIf yes, please describe briefly: 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 Peaceful Dark OtherIf other... please explain. CommentsCODE 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 of my 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.First NameLast NameDateSubmit Form
