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First Name:
*
Last Name:
*
Address:
City:
State:
Zip:
Phone Number:
*
Work Number:
Email:
*
Date of Birth:
*
Are you a Veteran
*
Yes
No
If so, which branch, and when did you serve?
How did you hear about our program?
Have you ever volunteered before?
Yes
No
If so, please describe:
Why are you interested in becoming a hospice volunteer?
Have you experienced a significant loss?
Yes
No
If yes, please share some details about your relationship and when it happened:
How often would you like to volunteer?
Daily
Weekly
Monthly
Other
Other:
Preferred Day of the Week
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Check all that apply
Time Preferences
Morning
Afternoon
Evening
Are you willing to participate for at least a year after training?
Yes
No
Please check the talents, abilities, hobbies, or skills that would be relevent as a hospice volunteer:
Compassion
Conversation
Reading
Writing
Music
Cooking
Light Housekeeping
Yard Work/ Gardening
Carfts (scrapbooking, cards, etc)
Running Errands
Pet Therapy
Manicures
Hairdressing
Grief Support to family after patient's passing (specific training required/provided)
Office Work
Computers
Special Events
Marketing Assistance
Other:
Highest Education Level Completed:
Highest Degree Earned:
Please list any specialized training or certifications you have:
Work History
Employed
Unemployed
Retired
Other
Employment status does not effect volunteer eligibility.
Briefly Describe your work experience:
Are you currently under the care of a physician?
Yes
No
Physician's Name:
Please list any medical or mental health problems/conditions:
Please list any perscription medications you currently take:
Do you have any physical limitations (lifting, bending, vision, hearing, etc)? Please explain:
Reference 1 Name:
*
Other than a relative
Reference 1 Phone:
*
Reference 1 Address:
Reference 1 Email:
Relationship
Personal
Professional
Other
Other:
How Long have you know this person?
1-3 years
3-5 years
5-10 years
10+
Reference 2 Name
*
Other than relative
Reference 2 Phone:
*
Other than relative
Reference 2 Address:
Other than relative
Reference 2 Email:
Other than relative
Relationship
Personal
Professional
Other
Other:
How Long have you know this person?
1-3 years
3-5 years
5-10 years
10+
Reference 3 Name
*
Other than relative
Reference 3 Phone:
*
Other than relative
Reference 3 Address:
Other than relative
Reference 3 Email:
Other than relative
Relationship
Personal
Professional
Other
Other:
How Long have you known this person?
1-3 years
3-5 years
5-10 years
10+
Have you ever been convicted of a misdemeanor or felony offence?
*
Yes
No
If yes, please explain:
Emergency Contact Name:
*
Relationship:
Address:
*
Home Phone:
*
Cell Phone:
*
Work Phone:
Agreement
*
I agree
I do not agree
By filling out this application to become a Patriot Hospice volunteer I agree to abide by the policies and procedures of the hospice program. I understand that I must favorably pass a background check, drug test, and reference check; submit to a PPD (Tuberculosis) test, and attend orientation and all necessary training. I also understand that all the required processes are provided by Patriot Hospice at no cost to me. I attest to the best of my knowledge all information submitted is correct.
Date:
*
Signature
*
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