Volunteer Applicant’s Information

First Name: *

Last Name: *

Address: *

City: *

State: *

Zip: *

Phone Number: *

Email: *

Military Service

Are you a Veteran? *

Yes

No

Branch:

Dates of Service:

Getting to Know You

How did you hear about our program? *

Have you ever volunteered before? *

Yes

No

If so, please describe:

On a scale of 1 (very uncomfortable) to 5 (very comfortable), what is your comfort level visiting and conversing with terminally ill patients & their families?

Why are you interested in becoming a hospice volunteer? *

Availability

Do you have reliable transportation to volunteer locations?

Yes

No

Time Preferences *

Morning

Afternoon

Evening

Approximately how many hours per month would you like to volunteer? *

Do you have any physical limitations you’d like Patriot to consider when matching you with a patient (lifting, bending, vision, hearing, etc)?

Education & Work

Highest Education Level Completed

Please list any professional license (including number), specialized trainings, or certifications you have (If none, enter N/A):

References

Reference 1 Name: *

Other than a relative

Reference 1 Phone: *

Reference 1 Address: *

Reference 1 Email: *

How long have you known this person? *

Relationship *

Personal

Professional

Other

Reference 2 Name *

Other than relative

Reference 2 Phone: *

Other than relative

Reference 2 Address: *

Other than relative

Reference 2 Email: *

Other than relative

How long have you known this person? *

Relationship *

Personal

Professional

Other

Reference 3 Name

Other than relative

Reference 3 Phone:

Other than relative

Reference 3 Address:

Other than relative

Reference 3 Email:

Other than relative

How long have you known this person?

Relationship

Personal

Professional

Other

Emergency Contact

Emergency Contact Name: *

Relationship *

Email Address: *

Cell Phone: *

Authorization & Signature

“I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.” *

I agree

I do not agree

Signature *

Clear

Date: *

Pre-Volunteer Record Check

Full Name

Date of Birth

All Previously Used Former or Other Names (AKA, Maiden Names, Married Names, Surnames, etc.):

Most Recent Address

City

State/Province

Zip/Postal

Most Recent Address

Additional Addresses from Past 3 Years

City

State/Province

Zip/Postal

Additional Addresses from Past 3 Years

City

State/Province

Zip/Postal

Additional Addresses from Past 3 Years

Social Security #

Your signature below indicates the following: You authorize, without reservation, Trak-1 or any third party to obtain and/or furnish to Patriot Hospice any records or information referenced in the provided disclosure statement for volunteer related purposes; You authorize ongoing procurement of any records or information, reports and records at any time during your relationship with Patriot Hospice to the extent allowed by law; You authorize the use of a fax or photocopy of this authorization as having the same authority as the original; You authorize and request, without reservation, any present or former employer, school, police department, financial institution, division of motor vehicles, consumer reporting agency, or other entity, person, or agency having knowledge about you to furnish Patriot Hospice and/or Trak-1 with any and all background information in their possession regarding you for these stated employment purposes; You understand and agree that in connection with your volunteer application consumer report information, whether investigative or otherwise, may be share with and/or reviewed by all applicable parties involved in the hiring process; You have read and fully understand the foregoing disclosure and this authorization. You certify that all the information you have provided on this form is true, complete, correct, and accurate; and You certify you have received, reviewed and understand “Summary of Your Rights under the Fair Credit Reporting Act (15 U.S.C. Code1681 et seq.)* which is published by the Federal Trade Commission to help you know your rights.

Signature

Clear

Date