Bonner Community Hospice Volunteer Application

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home

Area CodePhone Number

Work/Cell #

Area CodePhone Number

Email

example@example.com

Employer

Occupation

In case of emergency:

Emergency phone

Area CodePhone Number

Education/ Special Training:

Work Experience

How did you learn of hospice?

Have you ever lost someone close to you as a result of terminal illness? explain

What was your most recent significant encounter with death and when did it occur

Have you worked with dying people?

Explain the encounter

Describe any bereavement experience with family or friends

How do you feel about your own death?

Experience loss from divorce or separation in the last year?

YESNO

Describe experiences or activities that you believe to be important in your future work as a hospice volunteer:

What do you hope to receive from this kind of work?

What do you hope to give to the people with whom you work?

List workshops/training's attended or books read that are relevant to the hospice experience:

Do you speak a foreign language?

Which one's?

Skills, interests, hobbies:

Are you aware of any limitations we should know about?

YesNo

If yes, explain fully:

We require all volunteers to have a TB test. If you're over 35, you'll need to be tested twice. Do you object to this?

YesNo

We require all volunteers to have a urine drug screening. Do you object to this?

YesNo

Have you ever been convicted of a misdemeanor or felony?

YesNo

If yes, explain fully:

First Name Last Name

AddressPhone

First Name Last Name
AddressPhone

First Name Last Name
Address Phone

Interest in hospice for you is mainly (please check one or more):

How would you like to be of service to hospice?

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 professional 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 interpret “volunteer” to mean that I have agreed to work without compensation in 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.

I understand that any information that is disclosed to me while assisting the hospice is confidential.

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 information I acquire in the course of my volunteer activities with hospice.

Signature

Date

Volunteer Coordinator's Signature

Interview Date

Date

Bonner Community Hospice Volunteer Application

References