NEO Hospice Volunteer Application

Thank you for your interest in volunteering with Northeast Ohio Hospice!

Once we've received your completed application, we will contact you for a brief interview. Next, you will be asked to visit one of our Human Resources offices for a background check, including fingerprint capture. The process is brief and there is no cost to our volunteer applicants. Finally, all volunteers are required to have a two-step Mantoux/Tuberculosis (TB) skin test, administered by our staff at no cost to the volunteer. All Volunteers are required to have completed the COVID vaccinations and provide proof of their vaccination status.
Name
Address
City
State
Zip Code
Mobile phone
Home phone
Leave blank if not applicable
Work phone
Leave blank if not applicable
E mail address
example@example.com
Preferred Method of Contact

Mobile phoneE-mailWork phoneHome phone
How did you hear about our program?

News MediaCurrent StaffAnother VolunteerOur WebsitePatient or ResidentOther
Please note other volunteer work and/or memberships in service clubs or community organizations
Please note any special training (activities/hobbies/special interests) or skills that you have such as computer skills, teaching, foreign language skills, sewing, playing a musical instrument, or making crafts.
Last year of school completed
High School, college, university, etc.
Name of school
Please briefly explain why you are interested in volunteering

Your Availability:

	Mon	Tues	Wed	Thurs	Fri	Sat	Sun
Morning
Afternoon
Evening

Frequency

WeeklyMonthlyAs Needed
Number of times per week:
Number of times per month:
Please indicate community preference and interests listed below. Every attempt will be made to honor your preferences. However, the community needs, your time availability, and the interviewer's recommendation will be taken into consideration in determining our assignment.
ReadingCraftsSewingWood WorkComputerEscort ResidentsFundraisingGardeningPlaying Games/CardsReceptionistCooking and BakingTaking Care of AnimalsKnittingClub LeaderMusicAdministrative WorkSpecial EventsPaintingPlaying with ChildrenTransporting ResidentsOther
Applicant commitment and confidentiality statement:

I hereby certify that this information is true and complete. I understand that completion of this application does not obligate the organization to engage me on a voluntary basis. As a volunteer, I agree to abide by the organization's policies and procedures. I agree that all work I perform is on a volunteer basis and I am not eligible to receive any monetary payment or reward. I further understand that any work I perform becomes the property of the organization. I understand that I will be volunteering at my own risk and that the organization, its employees and affiliates, cannot assume any liability for any accident, injury, or health problem that may arise from my work for the organization. I understand that a background check and using electronic fingerprint recording will be conducted prior to my assignment as a volunteer. Opportunities for volunteers are provided without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, genetic information or any other legally protected status.
Signature

Clear
Date

MonthDayYear
Date
EMERGENCY CONTACTS

List the name(s) and phone number(s) of one or two friends or family members we can contact for you in the event of an emergency while you are engaged on the premises.

Type a question

	Name	Relationship	Work Phone	Mobile Phone	Email
Contact 1
Contact 2

Your Name
Date

MonthDayYear
Date
Signature

Clear
Long-term Care Background Check and Home & Community-Based Services Background Check Consent and Attestation Form

By signing this form, I consent to submission of a request for criminal records check (including database reviews) for long-term care and community-based services workers, as required by the Ohio Administrative and Revised Codes.

This request will be submitted to the Bureau of Criminal Investigations prior to employment and every five years if applicable and as determined by my employment status and location of employment. I also attest to the following:

1.That I have not been convicted of, or plead guilty to, any of the crimes that would disqualify me from working and volunteering with older adults under Senate Bill 160.

2.That I understand and agree that if I am found to have a record of any of those crimes, or if the organization does not receive a response from BCI/FBI within 30 days, I will not be permitted to work/volunteer with older adults or, if I have already begun working/volunteering, that my conditional employment/volunteering will be terminated.

3.That I was informed that I must provide a set of fingerprint impressions and that a criminal/records check must be conducted if I come under final consideration for working/volunteering.
I have resided in Ohio for the past five years

YesNo
Your Name
Signature

Clear
Date

MonthDayYear
Date
Tuberculosis Consent Form

By signing this form, you consent to receive the Tuberculosis testing as administered by the organization. To the best of my knowledge, I have not had a reaction to tuberculosis skin tests in the past.
Signature

Clear
Date

MonthDayYear
Date
Is this application for a minor?

NoYes
TB Test Consent for Minor Applicants Only

As a parent or legal guardian, I, the undersigned, do hereby give my consent for my son or daughter to receive the Mantoux (TB) testing as administered by the organization. To the best of my knowledge, my son or daughter has not had a reaction to tuberculosis skin tests in the past.
Applicant's Name
Applicant's Signature

Clear
Date

MonthDayYear
Date
Parent of Legal Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

EMERGENCY CONTACTS