Hospice Volunteer Application

Three Personal References (excluding family members)
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship*
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship*
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship*
VOLUNTEER APPLICANT'S STATEMENT. PLEASE READ CAREFULLY BEFORE SIGNING

The information given in this application to be a volunteer is true and complete to the best of my knowledge. I acknowledge that I have been informed that Care Initiatives Hospice is required to conduct a criminal and dependent adult abuse record check on me as condition of volunteering. Care Initiatives has my permission to obtain all necessary information from the references I have listed, or any other sources, concerning my prior work or volunteer experience. I release all parties from any possible damages resulting from disclosing such information with or without prior written notice to me. This signed statement, or a photocopy of the same, constitutes as a release to provide such information to this company.
Volunteer Applicant's Signature *

Clear
Date*

MonthDayYear
Date
Parent/Guardian Signature if applicant is under 18 years of age

Clear
Date

MonthDayYear
Date
Should be Empty:

Hospice Volunteer Application

Three Personal References (excluding family members)

VOLUNTEER APPLICANT'S STATEMENT. PLEASE READ CAREFULLY BEFORE SIGNING