Hospice of New York Volunteer Application

Volunteer Interest
Department of Interest?

Patient/Family VolunteerOfficeBereavement
Do you have a vehicle at your disposal?

YesNo
References

Reference 1
Last Name*
First Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*

Area CodePhone Number
Email*
example@example.com
Reference 2
Last Name
First Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Email
example@example.com
Reference 3
Last Name
First Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Email
example@example.com
How did you hear about Hospice of New York?
PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING THIS APPLICATION:

I authorize investigation of all statements contained in this application. I also authorize the person(s) whom I have listed as references to give pertinent information of my potential as a volunteer. I understand that misrepresentation or omission of the facts requested, or the receipt of unsatisfactory references will be reason for dismissal from volunteer service.
DateTime
Sign:

Clear
Should be Empty:

Emergency Contact