Volunteer Form

Address

Can you receive calls at work     Yes     No     Emergency Only

Person to be notified in an emergency:

Education/Special Training

Work Experience

Two Personal References (excluding family members). Please provide a complete address, as reference are verified by mail.

Identified Areas of Interest: (non-patient does not require 30 hour education course)

In Home   In Nursing Home   In Facility   Transportation   Personal Care   Meal Delivery   Alternative Therapies  

Caller   Home Visits   Support Group Co-Facilitator   Transportation   Office/Clerical   Memorial Service Committee

Clerical   Fundraismg   Mailings   Events   Marketing   Courier   Switchboard   Data Entry

Do you know a language other than English?     Yes     No

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?

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.

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.