Methodist Hospice Volunteer Application
Learn more about the program
Today's Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Social Security Number
*
Email
*
Confirmation Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is this your cell or home phone number?
*
Cell Phone
Home Phone
Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is this your cell or home phone number?
Cell Phone
Home Phone
Employer
Occupation
Person to be notified in case of emergency:
Name:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
*
How did you hear about the Methodist Hospice Volunteer Program?
*
Why do you want to be a hospice volunteer?
*
Areas of interest (check all that apply):
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Sitting with patients
Errands (for patients or hospice)
Clerical/office support
Comfort volunteer (Vigil - extra training required)
Bereavement program
Music therapy
Any specific services or skills you wish to offer?
Have you ever worked or volunteered in a healthcare setting?
*
Yes
No
Please describe:
Do you speak any foreign languages?
*
Yes
No
Which foreign languages do you speak?
Do you have access to reliable transportation?
*
Yes
No
Are you a veteran?
*
Yes
No
Have you ever been convicted of a felony or misdemeanor? (Do not assume expungement without court documentation.)
*
Yes
No
Please explain:
Do you currently have a pending felony or misdemeanor charge or an open arrest warrant?
*
Yes
No
Please explain:
Have you ever been ordered by a court to participate in a deferred prosecutionprogram such as diversion, adjudication, suspended sentence or othercourt-created alternative sanction?
*
Yes
No
Please explain:
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PERSONAL EXPERIENCES WITH DEATH, DYING, AND LOSS
In the past twelve months, have you experienced a significant change or loss? (Death, divorce, separation, move to a new community, change in job, etc.)
*
Yes
No
Please Specify:
When thinking of your own death, what words best describe death to you?
*
Sorrowful
Mysterious
Heavy
Natural
Painful
Peaceful
Frightening
Lonely
Dark
Joyful
Other
For "other," please specify:
What are your feelings about your own death?
*
Have you ever been with someone at the time of their death?
*
Yes
No
What was your most lasting impression of this experience?
Have you ever provided personal/nursing care to anyone?
*
Yes
No
Please, provide details:
Are you UNWILLING to volunteer in any of these environments? (Check all that apply)
Hospice Residence
Patient homes
Nursing homes
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Please provide three personal references. (Non-relatives)
Name:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Relationship
*
Name:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Relationship
*
Name:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Relationship
*
Submit
Should be Empty: