Hospice El Paso Volunteer Application Form
Thank you for your interest in volunteering. Please fill out the form below.
Date
*
-
Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday
*
In case of Emergency, Notify:
*
Name
Their Relationship to you
*
Phone Number
*
Please enter a valid phone number.
Are You currently attending school?
*
Yes
No
If yes, where?
Education/ Special Training/ Foreign Languages:
High School
College
How did you hear about volunteering for Hospice El Paso?
*
What made you decide to Volunteer?
*
Have you Volunteered before? If yes, where and in what positions?
List name of Company where you currently work (if not applicable please put N/A):
*
Phone Number
*
Please enter a valid phone number.
How long:
*
Position:
*
Supervisor Name
*
First Name
Last Name
References
Reference Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Reference Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Reference Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Qualifications
Have you ever been arrested or convicted of a misdemeanor or felony?
*
Yes
No
Please check to acknowledge the following statement:
*
A conviction record will not necessarily be a bar to selection as a volunteer. This information will be used only for volunteer related purposes and only to the extent permitted by applicable law.
Doyou have any physical restrictions that may affect yout placement with Hospice El Paso. If yes, what is the limitation:
Personal Doctor:
*
Doctor Telephone
*
Please enter a valid phone number.
When was your last TB test? (if not applicable, leave blank)
-
Month
-
Day
Year
Date
Have you had the Hepatitis B Vaccine?
*
Yes
No
Please check box to acknowledge the following statement:
*
All volunteer applicants are required to have a pre-acceptance physical and drug/alcohol screen
Areas of Interest (Administrative, Patient Visits, Crafts, etc.
*
Are you a veteran?
*
Yes
No
Foreign Languages:
Do you Drive?
*
Yes
No
Please check box to acknowledge statement
*
You will be required to provide Hospice El Paso with a copy of your driver's license or valid ID along with valid liability vehicle insurance unless you are using public transportation. A background check will be conducted upon acceptance.
Please check which role you are interested in Volunteering
*
Crafting
Veteran Pinning Ceremonies
Patient Companionship
Pet Therapy
Fundraising/Special Events
Administrative
Leading a volunteer project
Flowers from Friends/Delivery Visit
Center for Compassionate Care
Data Entry
Availability (Days and Times)
*
Acknowledgement and Consent...please check all boxes
*
The above information is accurate and correct to the best of my knowledge.
I understand that I am providing services strictly on a voluntary basis and that I have no expectation of compensation. I voluntarily waive, release and hold harmless Hospice El Paso, its elected and appointed officials, officers, employees, agents and other volunteers from any and all claims, causes of action and damages for bodily injury or death that I may suffer as a result of, or in any manner connected with, directly or indirectly, my participation as a volunteer when such bodily injury or death is the result of my own negligent or intentional acts or omissions or those of another volunteer. I understand that his waiver and release precludes my right to recovery of damages in the event I am injured in the course of performing my volunteer duties.
I shall defend, hold harmless an indemnify Hospice El Paso, its elected and appointed officials officers, employees, agents and other volunteers, from and against all damages, claims, liabilites, causes of action, judgements, settlements, costs and expenses (including, but not limited to reasonable expert witness and attorney fees) that may at any time arise or be claimed by any persona as a result of bodily injry, death or property damage, or as a result of any other claim or cause of action of any nature whatsoever, arising from or in any manner connected with, directly or indirectly, my negligent or intentional acts or omission in performing any and all volunteer duties.
Your signature indicates your approval for us to check personal references, perfrom a criminal history background check, OIG exlusion data check, drivers record check, perform an employee misconduct registry check/nurses aide registry check and contact your physician to determine if you are able to perform the duties of the volunteer position you have applied for in a reasonable and safe manner. The organization is not obliged to provide palacement, or are you obligated to accept the volunteer position offered. Opportunity for volunteers are provided without regard to religion, creed, national origin, age, or sex.
Save
Submit
Should be Empty: