Hospice Volunteer Application

Hospice Volunteer Application
Please Read before completing this application: This company does not discriminate in the recruitment, hiring, and conditions of employment (volunteering) on the basis of race, color, religion, national origin, sex, disability, age, or veteran status and any other applicable laws. Your completed application will be reviewed carefully. However, applying for Volunteer opportunities does not guarantee acceptance into this program. Volunteer consideration necessitates that you meet all minimum qualifications and requirements for the applied position.
PERSONAL DATA
Name
Phone/ Cell #
Mailing Address
Email Address
example@example.com
Employer
Employer:

Full TimePart TimePRN
Employer Address
Business Phone#
Emergency Contact #1
Phone/Cell #
Emergency Contact #2
Phone/Cell #
YES

Are you over the age of 18?NO If NO, are you at least 16 years of age?
YES

YESNO
GENERAL INFORMATION
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
YES

Do you have access to reliable transportation?NO
EDUCATION

High SchoolAssociate DegreeSome CollegeBachelor's DegreeMaster's DegreePost GraduateOther
PREVIOUS VOLUNTEER EXPERIENCE:
Organization
Type of Work
Organization
Type of Work
REFERENCES: (Professional or personal) Name
Address/Email Address
Phone/Cell
Relation
Time Known
md92k6n8kwssf1j-1
VOLUNTEER POSITION PREFERRED: (Please check boxes of interest)

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)Enrichment Services (music/art)
VOLUNTEER POSITION PREFERRED: (Please check boxes of interest)

ADMINISTRATIVE SUPPORT (Data entry, filing, copying, assistance with mailings, etc.)OTHER:
Companionship/ Socialization/ Caregiver Relief

DIRECT PATIENT CARE
Vigil Volunteering (sitting with and attending to our actively dying patients)
OTHER
OTHER
Do you speak a foreign language?

YESNO
Specify
Are you an active service member/ Veteran?

YESNO
Specify
Other skills and interests?
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 Gentiva 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 Manual and description. I agree to a background investigation.
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 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 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 Gentiva.
Printed Name
Should be Empty:

Hospice Volunteer Application

PERSONAL DATA

GENERAL INFORMATION

PREVIOUS VOLUNTEER EXPERIENCE:

CODE OF ETHICS FOR VOLUNTEERS

DECLARATION