Application for Volunteer Work

Application for Volunteer Work

1320 Linglestown Rd, Harrisburg PA 17110 PH: 717-732-1000 www.hospiceofcentralpa.org / volunteers@hospiceofcentralpa.org
DATE

MonthDayYear
Date
Name*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone
Cell Phone
Email Address*
example@example.com
Availability and Interest
When can you attend volunteer training?*

DaytimeEveningNo preference
When are you available to provide regular volunteer service?

WeekdaysWeekday eveningsWeekend daytimeWeekend evenings
Do you hold a valid PA drivers' license?*

yesno
Do you have access to a vehicle for your volunteer work?*

yesno
Please indicate the areas of volunteering you would like to consider:*

Patient care and family supportClerical/administrative supportHospice residence and nursing homesBouquets of LoveVeteran to VeteranCommunity outreach/educationPet therapySpecial events / fundraising projectsMusic supportBereavement supportLegacy workCamp Dragonfly
Demographics

Completion of this section is optional. These questions may seem unduly personal, however, they will be helpful in making future volunteer assignments.
Gender
Martial status

singlemarriedwidoweddivorced
Date of birth*

MonthDayYear
Date
Ethnic background
Religion
Fluency in other languages
Are you a veteran?
EDUCATION
Highest year or degree attained*
Year education completed
Name and address of school attended
Employment Information
Currently employed?*

YesFull timePart timeNoRetired
Employer
Phone
Address
Position/job title
Dates of employment
Previous employers
Company
Years
Address
Phone Number
Please enter a valid phone number.
Company
Years
Address
Phone
List any professional credentials you hold, including license # and date of expiration:
Have you ever worked or volunteered for a hospice agency? If so, give name, address of agency, years employed, and position held.
References

Please provide the names, email addresses, and phone numbers of three (3) persons not related to you whom we may contact. Indicate the relationship and how long you have known the person.
Reference #1*
Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Relationship*
Relationship and length of relationship
Reference #2*
Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Relationship*
Relationship and length of relationship
Reference #3*
Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Relationship*
Relationship and length of relationship
LIFE EXPERIENCES AND INTERESTS
1. Please explain briefly why you are interested in becoming a volunteer for Hospice of Central Pennsylvania.*
2. Have you had any personal experiences with death and dying? Please describe briefly indicating the years of each experience.*
3. What other volunteer work are you currently involved in? Please give agency names and positions held.*
4. What volunteer work have you been involved with in the past?*
5. How did you hear about Hospice of Central PA and/or volunteer training?*
6. Please list your hobbies or special interests:
Liability
Have you ever been convicted of a crime?*

YesNo
If yes please explain
Have you had your driver's license suspended?*

YesNo
If yes please explain
Have you ever been convicted of a crime or dismissed from employment or volunteer service due to sale or use of controlled substances, sexual misconduct, or the abuse, neglect, or physical violence involving other persons?*

YesNo
Have you ever been bonded?*

YesNo
Have you ever been named as a perpetrator in an indicted or founded report of child abuse?*

YesNo
Commitment
Are you willing to train in hospice care for 20+ hours?*

YesNo
Are you willing to provide about four (4) hours a week to hospice when actively involved with patients/families?*

YesNo
Will you be able to attend monthly continuing education/support meetings after becoming a HCP volunteer?*

YesNo
To the best of my knowledge the information contained in this application is true and correct. I understand that any false information may result in my application being denied, or my volunteer status being terminated. Further, I give Hospice of Central PA permission to contact the references and employers named in this application and do criminal background checks on the above information provided.
SIGNATURE*

Clear
DATE*

MonthDayYear
Date
HCP complies with Title VI of the Civil Rights Act 1964, and the Rehabilitation Act 1973, and the Age Discrimination Act 1975.
Should be Empty:

Application for Volunteer Work

Availability and Interest

Demographics

EDUCATION

Employment Information

References

LIFE EXPERIENCES AND INTERESTS

Liability

Commitment