Creekside Hospice

VOLUNTEER APPLICATION

Volunteer Application

Name Date
Street Address
City State Zip

Home Phone Cell Fax
Email Address:

Employer
Business Address
Work Phone Position Help

Highest Level of Education Completed Where
Any other training or seminars?
Are you a U.S. Veteran? Which Branch?
Are you presently attending school? Where?
Courses

Do you speak a second languarge? Read? Write?
If Yes, which language(s)?

Do you access to a car? Yes No
Willing to provide proof of auto insurance & driver’s license? Yes No
How far are you willing to drive to volunteer?

Which day(s) are best for you to volunteer?
Time(s)?

How did you hear about Creekside Hospice?

Areas of Interest

Office Support:
Clerical Data Entry Answer Phones Mailings
Other (explain):

Patient Support Bereavement Support
I am willing to be assigned to a smoker: Yes No
I can be assigned to a home with cats or dogs: Yes No

Previous Volunteer Experience

Have you been a Hospice Volunteer before?
If Yes, name of Hospice
Street Address
City State Zip
Volunteer Coordinator’s Name:
Phone Type of volunteer work

Why do you want to become a volunteer?

Personal References:

Name Phone
Street Address
City State Zip
How long known: Relationship:

Name Phone
Street Address
City State Zip
How long known: Relationship:

Name Phone
Street Address
City State Zip
How long known: Relationship:

I authorize an investigative report to be made whereby information is obtained through personal interviews with third parties. I understand and consent to an inquiry that may include information as to my character, general reputation, and personal characteristics, whichever may be applicable. I hereby release from all liability or responsibility all persons, companies, organizations or corporations furnishing such information.

I am willing to adhere to the rules and regulations of the Foundation for Creekside Hospice to the best of my ability. I agree to respect the clients confidentiality. I understand that I will begin service on a reciprocal trial basis.

Volunteer’s Name Date