Volunteer Application

Name of Applicant:

Date of Birth:

Address:

City:

State: Zip:

Home/Cell Phone:

Work Phone:

Email:

Employer:

Occupation:

Can you receive calls at work?

Emergency Contact

Name:

Relation:

Address:

City:

State: Zip:

Phone:


Educational/Special Training:

Work Experience:

Two Personal References (excluding family members). Please provide complete address as references are verified by mail.

Reference 1:

Name:

Phone:

Address:

City:

State: Zip:

Reference 2:

Name:

Phone:

Address:

City:

State: Zip:

Areas of Interest:

Patient/Family Care

Bereavement

Non-Patient Services

Do you know a language other than English?

Language

Language

Other special services: (manicurist, hairdresser, massage):

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 your 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?

If yes, please describe:

Have you ever provided care to anyone who was dying?

If yes, please describe:

When thinking of your own death, what words best describe death to you?



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 professionals 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 Hearts for Hospice is confidential.

I interpret “volunteer” to mean that I have agreed to work without compensation of 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 of my knowledge. I 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 i nformation I acquire in the course of my volunteer activities with Hearts for Hospice.