Touchstone Hospice Volunteer Application

Date

PLEASE ANSWER ALL QUESTIONS. RESUMES ARE NOT A SUBSTITUTE FOR A COMPLETED APPLICATION

We are an equal opportunity employer. Volunteer applicants are considered for positions without regard to veteran status, uniformed servicemember status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state, or local laws. Applying for Volunteer opportunities does not guarantee acceptance into this program. Volunteer consideration necessitated that you meet all minimum qualifications and requirements for the applied position.

THIS COMPANY IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF SELECTED, THE COMPANY OR I MAY TERMINATE THE VOLUNTEER RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE.

Position Applied For

Name

First NameLast Name

Telephone number

Please enter a valid phone number.

Alternate/Cellular Telephone Number

Please enter a valid phone number.

Present Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address

example@example.com

Current Employer

Select

Full timePart time

Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Business Phone

Please enter a valid phone number.

Emergency Contact

Phone/Cell

Please enter a valid phone number.

Are you over the age of 18?

YesNo

How were you referred to our company?

Specific name of referral source indicated above, if applicable:

When are you available to volunteer?

WeekdayWeekend(s)School YearOther

Do you have access to reliable transportation?

YesNo

Have you ever pleaded guilty to or been convicted of a criminal offense

YesNo

If yes, give dates and circumstances

Are you currently, or have you ever been, suspended, debarred, or otherwise or otherwise excluded from participation in any federal or state health care program?

YesNo

Have you ever been involuntarily discharged from a position, paid or Volunteer?

YesNo

If yes, give dates and circumstances

CONVICTIONS: A conviction does not automatically mean you will be unable to volunteer. What you were convicted of, the circumstances surrounding the conviction and how long ago the conviction occurred are all important considerations in determining your eligibility. Please share all the facts to ensure a fair decision process

If applicable, below list any other names by which you have been known which may be necessary to allow us to confirm your work and educational record. For example, change of name, use of an assumed name, nickname etc.

Select

Organization

Type of Work

Organization

Type of Work

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Relationship

Time Known

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Relationship

Time Known

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Relationship

Time Known

Select

Patient SupportAdministrative Support (Data entry, filing, copying, assistance with mailings, etc.)Other

If selected Patient Support, please select below

Companionship/socialization/caregiver reliefAssistance with meal preparation/light household choresSpiritual/bereavement/emotional supportVigil Volunteering (sitting with and attending to our actively dying patients)Veteran VolunteersPet therapy (requires certification of therapy animal)Massage therapy (requires licensure within the State of Texas)Enrichment services (music, art, etc.)

Do you speak a foreign language?

YesNo

Are you an active service member/ Veteran?

YesNo

Other skills and interests?

CODE OF ETHICS FOR VOLUNTEERS

As a Volunteer, I realize 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 accountability for my work and will seek to fulfill my responsibilities to the best of my ability. I understand that any information disclosed to me while assisting Touchstone Health is confidential. I interpret my role as Volunteer to mean that I have agreed to work without monetary compensation. Having been accepted as a Volunteer, I will do my work according to the standards set forth in the Volunteer Orientation Training Manual and job description. I agree to a background investigation.

I understand and agree that if driving is a requirement of the Volunteer position for which I am applying, my service as a Volunteer is contingent on possessing a valid driver’s license for the state in which I reside and automobile liability insurance in an amount equal to the minimum required by the State of Texas.

I understand that the Company may now have or may establish a drug-free workplace or drug and/or alcohol testing program consistent with applicable federal, state, and local law. If the Company has such a program and I am offered a conditional offer of Volunteering, I understand that if pre-volunteer (post-offer) drug and/or alcohol test is positive, the offer may be withdrawn. I agree to work under the conditions requiring a drug-free workplace, consistent with applicable federal, state, and local law. I also understand that all employees and Volunteers, pursuant to the Company’s policy and federal, state, and local law, may be subject to urinalysis and/or blood screening or other medically recognized tests designed to detect the presence of alcohol or illegal or controlled drugs. If selected as a Volunteer, I understand that the taking of alcohol and/or drug tests is a condition of continual service and I agree to undergo alcohol and drug testing consistent with the Company’s policies and applicable federal, state, and local law.

If selected by the Company, I understand and agree that the Company, to the extent permitted by federal, state, and local law, may exercise its right without prior warning or notice, to conduct investigations of property (including, but not limited to, files, lockers, desks, vehicles, and computers) and, in certain circumstances, my personal property.

I understand and agree that as a condition of volunteering and to the extend permitted by federal, state, and local law, I may be required to sign a confidentiality, restrictive covenant, and/or conflict of interest statement.

IF SELECTED, I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF THE COMPANY, AND I UNDERSTAND THAT THE COMPANY HAS COMPLETE DISCRETION TO MODIFY SUCH RULES AND REGULATIONS AT ANY TIME, EXCEPT THAT IT WILL NOT MODY ITS POLICY OF EMPLOYMENT AT-WILL.

I authorize the Company or its agents to confirm all statements contained in this application and/or resume as it relates to the position, I am seeking to the extent permitted by federal, state, and local law. I agree to complete any requisite authorization forms for the background investigation which may be permitted by federal, state, and/or local law. If applicable and allowed by law, I will receive separate written notification regarding the Company’s intent to obtain “consumer reports.”

I authorize and consent to without reservation, any party or agency contacted by this Company to furnish the above-mentioned information. I hereby release, discharge, and hold harmless, to the extent permitted by federal, state, and local law, any party delivering information to the Company or its duly authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action which I may have as a result of the delivery or disclosure of the above requested information. I hereby release from liability the Company and its representative for seeking such information and all other persons, corporations, or organizations furnishing such information. Further, if selected, I authorize the company to provide truthful information concerning my service to future organizations where I may seek to serve as a Volunteer and hold the company harmless for providing such information.

THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF SIXTY (60) DAYS. IF YOU WISH TO BE CONSIDERED FOR A VOLUNTEER POSITION AFTER THAT TIME, YOU MUST REAPPLY.

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 and consenting for a background investigation I am authorizing inquiries to be made concerning my employment, character, and public records for the sole purpose of determining my suitability as a Volunteer. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for Volunteering and if selected, disciplinary action, up to and including immediate dismissal. 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 patient or family in the course of my Volunteer activities with Touchstone Health.

DO NOT SIGN UNTIL YOU HAVE READ ALL OF THE INFORMATION CONTAINED IN THE APPLICATION

Signature

Date

Touchstone Hospice Volunteer Application

PERSONAL DATA

GENERAL INFORMATION

EDUCATION

PREVIOUS VOLUNTEER EXPERIENCE

REFERENCES

VOLUNTEER POSITION PREFERRED

APPLICANT CERTIFICATION