Hospice Volunteer Application Learn More About Hospice Volunteers Hospice Volunteer ApplicationName First Last Address Street Address City ZIP / Postal Code Home PhoneWork PhoneCell PhoneEmail Person to be notified in an emergency:Name First Last PhoneAddress Street Address City ZIP / Postal Code EmployerEmployerOccupationCan receive calls at work (please check one):YesNoEmergency onlyEducationEducation completedPlease list any Professional License, Certification, or Registration that you may have:Please include Type, Number, State(s), & Expiration Date:Are you a veteran? Yes No If so, what branch of service?Education/Special Training:Work experience:Other special services/skills:Do you speak or have basic proficiency in any other languages?Volunteer History:What do you look for in a volunteer experience?How did you hear about our Hospice volunteer program?Why do you want to be a hospice volunteer?Do you have access to transportation?YesNoDeath and Dying AwarenessHave you ever been with someone at the time of their death?YesNoIf yes please describe briefly:Have you ever provided care to anyone who was dying?YesNoIf yes please explainPlease list significant losses that have occurred in your life and your age at the time of each.Ability to Volunteer: Mornings Afternoons Evenings Weekdays Weekends Specific availability:Can you commit to volunteering a minimum of three hours per week for a year?YesNoIn what regions are you available to serve? Missoula City Missoula area (15 miles out) N. Bitterroot Valley S. Bitterroot Valley Superior area Polson area Seeley Lake area Bonner-Drummond St. Ignatius/Arlee area Other :Are you available to provide respite on occasion for extended periods (3-6 hours)?YesNoAreas of InterestServices you would like to offer.PATIENT/FAMILY CARE(check all that apply & specify where appropriate) In Home In Facility Companionship Respite Pet Therapy Music Art Reiki Aromatherapy Arts & Crafts Card games Puzzles Reading Vigil service Life Review Transport patients (appts, shopping) Shopping/errands Lawn care/ Snow shoveling Housekeeping Handyman Carpentry Auto Maintenance/ Repair/ Cleaning Hair/ Manicure/ Pedicure Sewing/ Quilting Board games Scrap booking Photography Outings Bible reading More info about the kind of music, art, arts & crafts or other specific services you would like to offer...NON-PATIENT CAREcheck all that apply Bereavement calls Bereavement mailings Office/clerical Mailings Tree of Life Fundraising Events Marketing Data entry Assist with trainings Other:Do you have any passions/interests that would be helpful for us to know about?ReferencesList two personal references (excluding family members):Name First Last PhoneCityName (2nd reference) First Last Phone (2nd reference)City (2nd reference)State (2nd reference)Have you ever been convicted of a felony? Yes No If yes, please explainPlease note that a background check is required. Thank you for your interest in volunteering for Partners Hospice! Please read, and check the box to acknowledge your signature. I certify that the information I provided in this Hospice Volunteer Application is true and complete to the best of my knowledge. I authorize Partners In Home Care to contact my previous employers and other resources to investigate any of the facts set forth in this Application. I specifically waive prior written notice of disclosure of any personnel record information, including disciplinary reports, letters of reprimand or other disciplinary action. In consideration of acceptance of my application, I release Partners In Home Care and my previous employers of any claimed liability arising out of such response and disclosure.Acknowledge Signature Date Date Format: MM slash DD slash YYYY CAPTCHA
