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Volunteer Form

Interested in volunteering with us?

Use The Form Below To Submit Your Application

Volunteer Application Form

"*" indicates required fields

Please select from the dropdown below.*

At which location are you interested in volunteering?*

Your Information

Your Name*

First Last

Phone Number*

Email*

Volunteer Information

Your Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone Number*

Emergency Contact

First Name*

First Last

Relationship*

Emergency Contact Phone*

Background

Do you have any medical problem, injury, physical limitations, chronic ailment, or other condition that could affect your ability to perform volunteer work?*

Yes

No

Have you ever tested positive for tuberculosis?*

Yes

No

Have you ever been convicted of a felony?*

Yes

No

If so, where?

Have you experienced a personal loss in the past year?*

Yes

No

Are you a veteran?*

Yes

No

If so, which branch of service?

T-Shirt Size*

Are you wanting to volunteer as a requirement for school?*

Yes

No

If so, how many hours does your school require?

Employment / Interests / Skills

Are you currently employed?*

Yes

No

Retired

Employer

Position

Do you drive and have a valid driver's license?*

Yes

No

Do you have auto insurance?*

Yes

No

Please list any educational background, hobbies, skills, and special interests (office, arts, crafts, etc.) that you feel could be helpful to your volunteer experience*

Why do you wish to be involved in hospice?*

Areas of Interest*

Patient / Family Care

Certified Pet Therapy

Administrative Support

Sewing / Craft Team

Sewing / Craft Team

Bereavement Phone Team

Speakers Bureau

Other

Special Services

Music Enrichment

Art Enrichment

Hair Stylist

Lawn Care

Light Carpentry

Other

Is there any segment of the population that you would have difficulty serving?*

Yes

No

If so, which population?

Would you mind being around animals?*

Yes

No

Would you mind being around smokers?*

Yes

No

Reference 1

First Name*

First Last

Phone*

Email

Reference 2

First Name*

First Last

First Name*

First

Phone*

Email

Reference 3

First Name*

First Last

Phone*

Email

Consent

Confirmation*

I hereby confirm that the above information has been field out to the best of my ability and correct to my knowledge.

Name*

First Last

Date*

MM slash DD slash YYYY

Parent / Guardian Confirmation*

I am over 18 years of age.

I am under 18 years of age, and I herby confirm that the person below is my parent or guardian.

Name Of Guardian*

First Last

Date*

MM slash DD slash YYYY

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