Hospice Volunteer Form

Application for Hospice Volunteer Service
First Name*
Last Name*
MI
Mailing Address*
Town*
State*
Zip*
Home Phone
Cell Phone
Email Address
example@example.com
In Case of Emergency, Contact:
Name
Home Phone
Relationship to you
Are you (please check one)

EmployedUnemployedRetired
I am at least 18 years old*

YesNo
How did you hear about this opportunity?
List any professional licenses or certifications you currently hold
Please explain why you want to volunteer and what you hope to accomplish volunteering
Please explain why you want to volunteer and what you hope to accomplish volunteering
You may also be interested in Non-Patient Services such as: (check any that apply)

ClericalFundraisingEventsMarketingMailings
When are you able to start?
How many hours weekly would you like to volunteer?
What times do you prefer to volunteer? (please check)

MorningAfternoonEvening
What days do you prefer to volunteer? (please check)

SundayMondayTuesdayWednesdayThursdayFridaySaturday
The Healthy Link Between People, Family and Community
Will you be away from your volunteering for extended periods of time?
How long do you expect to volunteer? (please check)

Less than 6 monthsOne yearLonger than one yearThe school year (Sept. - June)
Have you ever volunteered; if yes, please list organizations
Have you ever been employed by Community Health and Counseling Services?
Do you have access to transportation?*

YesNo
Please list two personal references familiar with your interests, skills and abilities with people.
Name
Phone
How does this person know you?
Name
Phone
How does this person know you?
Volunteer position offers are contingent upon:
1. Receipt of acceptable recommendations from references.
2. Departmental or program approval.
3. Completion of the Volunteer required immunizations.
4. Criminal background check
5. Driving History Check
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 filed 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 this application are true and correct to the best of my knowledge. I understand that, by submitting this application I authorize inquires 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 patient information I acquire in the course of my volunteer activities with CHCS Hospice.
Applicant Signature*

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Application for Hospice Volunteer Service

The Healthy Link Between People, Family and Community

Please list two personal references familiar with your interests, skills and abilities with people.

Code of Ethics for Volunteers

Declaration