Hospice Services of Georgia and South Carolina Volunteer Sign-Up

Volunteer Sign-Up

This company does not discriminate in the recruitment, hiring, and conditions of employment (volunteering) on the basis of race, color, religion, nation of origin, sex, disability, age, or veteran status, and any other applicable laws. Your completed application will be reviewed carefully, however, applying for volunteer opportunities down not guarantee acceptance into this program. Volunteer consideration necessitates that you meet all minimum qualifications and requirements for the applied position.
Full Name

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What areas of coverage are you willing to travel to in Georgia? Check all that apply.
What areas of coverage are you willing to travel to in South Carolina? Check all that apply.
What days are you available to volunteer? Check all that apply.
We offer a variety of meaningful volunteer opportunities to match your interests, talents, and availability. Please select the areas that interest you most.

Other
Other areas of interest:
How did you hear about us?

Do you have reliable transportation?

Do you speak a foriegn language?
Yes   No
If yes, specify
Are you an active service member or veteran?
Yes    No
Have you ever pleaded guilty to or been convicted of a criminal offense?
Yes  No
If yes, give dates and circumstances
Are you currently, or have you ever been suspended, debarred, or otherwise excluded from participation in any federal or state health care program?
Yes   No
If yes, give dates and circumstances

CONVICTIONS: A conviction does not automatically mean you will be unable to volunteer. What you were convicted of, the circumstances surrounding the conviction and how long ago the conviction occurred are all important considerations in determining your eligibility please share all the facts to ensure a fair decision process.

References (Professional or Personal)

Rows	Name	Phone Number	Email	Time Known
Reference 1
Reference 2

CODF 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. l, 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 Hospice Services of GA/SC 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 guidelines.

DECLARATION
I hereby certify that the statements 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 this Hospice Services of GA/SC.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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