Hospice Care Volunteer Application
Date
*
/
Month
/
Day
Year
Date
Applicant / Family Data
Name
*
First Name
Last Name
Email
*
example@example.com
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
/
Month
/
Day
Year
Date
Age
Emergency Contact
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship to You
*
Education
School Attended
Degree
Major
School Attended
Degree
Major
Employment / Professional Affiliations
Occupation
Employer
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employment History:
Previous Job & Employer 1
Dates
Description of Work
Previous Job & Employer 2
Dates
Description of Work
Professional Affiliations / Honors
Volunteer Information
Why do you want to be a Hospice Volunteer?
Time available for volunteering?
Days
Evenings
Weekends
Do you have previous volunteer experience? If so, please describe:
Please describe some of your special talents, attributes and skills:
Are you fluent in any languages other than English? If so, please list:
What sort of work would you like to do for hospice? Check all that apply
Volunteer service to patient and family (tasks such as respite, errands, companionship, support)
Quality Advocacy Phone Calls
Veteran to Veteran
Spiritual Support
Bereavement
Music Volunteer
Hildebrandt
Pet Therapy
Nursing Home Visits
Reiki
Office Work (data entry, mailings, filing)
Massage Therapy
Has someone close to you died recently? (if yes, please explain)
References
Please list (3) references
(not relatives)
Reference 1 Name
*
First Name
Last Name
Reference 1 Relationship
*
Reference 1 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reference 1 Phone
*
Format: (000) 000-0000.
Reference 1 Email
*
example@example.com
Reference 2 Name
*
First Name
Last Name
Reference 2 Relationship
*
Reference 2 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reference 2 Phone
*
Format: (000) 000-0000.
Reference 2 Email
*
example@example.com
Reference 3 Name
*
First Name
Last Name
Reference 3 Relationship
*
Reference 3 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reference 3 Phone
*
Format: (000) 000-0000.
Reference 3 Email
*
example@example.com
Signature of applicant
*
Date
*
/
Month
/
Day
Year
Date
For Office Use Only
Interviewer’s Comments
Signature of Interviewer
Date
/
Month
/
Day
Year
Date
Submit
Should be Empty: