Volunteer Application

Volunteer Application
Thank you for your interest in volunteering with HealthView Hospice & Palliative Care. Volunteers are an essential part of our care team. They offer companionship, comfort and practical help to patients and their families.

This application takes about 10 to 15 minutes. After we review it, our Volunteer Coordinator will contact you to schedule an interview.

Requirement: Must be at least 18 years or older
Applicant Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship to you
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Volunteer Interests
Which volunteer roles interest you? Select all that apply.
Where are you comfortable volunteering? Select all that apply
Special skills, hobbies or talents you would like to share (for example music, hair care, crafts, sewing, photography, notary services)
Do you hold a current professional license or certification? (For example RN, LVN, CNA, chaplain, social worker, massage therapist, cosmetologist)
Are you a U.S. military veteran? (We ask so we can match veteran volunteers with veteran patients.)
Availability and Transportation

When are you generally available?

Rows	Morning	Afternoon	Evening	Flexible
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

How many hours per week can you offer?
Earliest date you could start

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Can you commit to volunteering for at least 3 months?
Which cities or areas are you able to travel to?
Do you have reliable transportation?
Do you have a valid driver's license and current auto insurance?
Background and experience
Current Status
Employer or school
Have you volunteered with a hospice before?
If yes, which hospice and in what role?
Other volunteer experience (paid or unpaid, including caring for a family member)
Experience in healthcare or caregiving
Are you volunteering to meet school, pre-health or service-hour requirements?
If yes, how many hours do you need and by what date?
Motivation and personal readiness
Why do you want to volunteer with hospice?
What do you hope to gain from volunteering?
How comfortable are you spending time with people who are seriously ill or near the end of life?
Have you experienced the death of someone close to you in the past 12 months? (a recent loss does not disqualify you. We ask so your Volunteer Coordinator can talk with you about the roles and timing that fit best.)
Is there anything else that would help us place you well?
References

Please list two people who know you well and are not related to you, such as a supervisor, teacher, colleague, faith leader or volunteer coordinator.
Reference 1 name

First NameLast Name
Reference 1 relationship to you
Reference 1 phone
Please enter a valid phone number.Format: (000) 000-0000.
Reference 1 email
example@example.com
Reference 2 name

First NameLast Name
Reference 2 relationship to you
Reference 2 phone
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2 email
example@example.com
Program Requirements
Before starting, every HealthView hospice volunteer completes the following:

-An interview with the Volunteer Coordinator
-Volunteer orientation and training
-A criminal background check
-Tuberculosis (TB) screening and any other health screening HealthView requires
-HealthView's confidentiality (HIPAA) agreement
-Proof of a driver's license and auto insurance, if the role involves driving
I understand these requirements and am willing to complete them if I am selected.
I understand that volunteering is unpaid and that submitting this application does not guarantee placement.
Certification and signature
Certification. I certify that the information in this application is true and complete to the best of my knowledge. I understand that false or incomplete information may result in my application being declined or my volunteer service ending. I authorize HealthView Hospice & Palliative Care to contact the references I have listed.

Confidentiality. I understand that any patient or family information I learn during the application, training or volunteer process is confidential and may not be shared with anyone outside the HealthView care team.
I have read and agree to the statements above.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Volunteer Application

Applicant Information

Emergency Contact

Volunteer Interests

Availability and Transportation

Background and experience

Motivation and personal readiness

References

Program Requirements

Certification and signature