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 PRINT
