• Hospice of Jefferson County Volunteer Application

  • Gender
  •  -
  •  -
  • Are you over the age of 18?
  • DOB
     - -

  • Emergency Contact

    In case of an emergency please notify:
  •  -

  • Education

  • Please check highest level completed*

  • Are you currently in school?*

  • Military Experience:*

  • Skills

  • Interests and Certifications (please check all you’d be interested in sharing with us)

  • Time Availability (Choose all that apply)

  • Experience

  • Have you ever had experience with groups, such as support groups or self-help groups?
  • Are you fluent in any foreign languages?*
  • Have you had any personal experience with hospice?*

  • Desired Area of Volunteering

    (Please check all that apply)
  • Direct Care (Patient & Family Care)
  • Bereavement (two hours additional training isrequired to be a bereavement volunteer)
  • Administrative Services (non-patient services)

  • Three Personal References

    (Please provide complete address)
  •  -

  • Reference 2
  •  -

  • Reference 3
  •  -

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

    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.

    Declaration

    I hereby certify that the statements made on the 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.

  • Should be Empty: