Volunteer Application

Application Process

1. Complete the online application and submit.

2. You will be contacted by a Volunteer Coordinator within 3 business days. At that time, you will be given:

a link to initiate your background check.
details about your orientation.

3. Please note: A background check is required because we work with sensitive data and a vulnerable patient population.

Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Birth Date

Date

Current Occupation

Emergency Contact

Emergency Contact's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Relationship of Emergency Contact

Which area(s) are you interested in serving in?

Please enter other locations (if applicable)

What area of volunteering are you interested in?

Please enter other areas of interest or special skills (if applicable)

Do you have reliable transportation?

Are you a Veteran?

If yes, what branch?

Years Served

Why would you like to volunteer for Our Hospice?

Personal Reference #1

Name

Address

Phone Number

Relationship

Personal Reference #2

Name

Address

Phone Number

Relationship

Please Read and Initial Each of the Following Statements.This Application is Invalid Without Your Initials and Signature Below.

ACCURACY OF INFORMATION PROVIDED AND SIGNIFICANCE OF THIS APPLICATION: I certify that all information on this application is correct and true to the best of my knowledge. I understand that any false statement, omission, or misrepresentation is sufficient cause for refusal to be considered for volunteer placement. Please initial here: Initials* .

PRE-HIRE DRUG TESTING: I understand that Our Hospice of South Central Indiana requires all volunteers to successfully pass a substance abuse test as a term and condition of volunteering. If the results of such tests indicate the presence of any illegal, controlled, or unauthorized drugs in my blood or urine, I will not be eligible to volunteer. I have read, understand and agree to the above statements. Please initial here: Initials* .

DRUG FREE WORKPLACE COMPLIANCE: I understand that the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance on company premises or while conducting company business off company premises is absolutely prohibited. I agree as a condition of volunteering, to abide by the terms of the Drug-Free Workplace Act of 1988 and any policies relating to this Act and to report any conviction under a criminal drug statue for violations occurring on or off company premises while conducting company business within five (5) days after such conviction. I further understand and agree that I may berequired to submit to alcohol / drug testing under circumstances giving rise to reasonable suspicion of alcohol / drug use during myemployment and that my refusal to submit to such testing is grounds for immediate termination of my employment. I have read, understandand agree to the above statements.. Please initial here: Initials* .

AUTHORIZATION TO INVESTIGATE BACKGROUND and References: Our Hospice of South Central Indiana, in considering my application for volunteering, may verify the information set forth on this application and obtain additional information relating to my background. I authorize all persons, companies, and law enforcement agencies to supply this Our Hospice any information concerning my background and consent to the release of such information. I authorize Our Hospice to investigate all information and release Our Hospice and all persons, companies, corporations, and law enforcement agencies from all liability and responsibility for furnishing any information concerning my background or confirming the information in this application. Please initial here: Initials* .

I have read and agree with all the above statements. Signature* Date