Hospice of Dickinson County Volunteers – online application

Date / Time *

ABOUT YOU

Name *

First

Last

Birthdate (for birthday card list ONLY)

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Email

Confirm Email

What is the best way to reach you? *

Call Me!
Text Me!
Email Me!

DAYS/TIMES YOU ARE AVAILABLE TO VOLUNTEER

Please choose all times available: *

Employer

Work Phone #

Are you able to receive calls at work?

Yes
No

Occupation

Education and/or Special Skills and Training: *

Work Experience: *

BACKGROUND DATA

Have you ever been convicted of a criminal offense, other than a minor traffic offense? *

Is there any type of service which your health or physical condition prohibits - or have you ever been advised by a physician NOT to perform certain types of work or recreation? *

INTERESTS/SKILLS

What hobbies do you enjoy?

How did you hear about this volunteer program?

Why do you want to be a volunteer for Home Health & Hospice? *

Please check all of the volunteer opportunities that interest you!

What qualities (skills, talents, knowledge, etc.) do you feel you can incorporate into your hospice volunteer work?

Other special services you could offer? (manicurist, hairdresser, home maintenance, etc.)

What are your thoughts and feelings about death? (please describe)

Have you ever been with someone at the time of their death? (please describe)

Have you ever provided care to anyone who was dying? (please describe)

When thinking about your own death, what words best describe death to you?

Any other comments you have about your own death?

Do you know another language other than English?

Yes
No

Language

Speak
Read
Write

Do you have access to reliable transportation?

Yes
No

REFERENCES (excluding family members)

Please provide a complete address as references are verified by mail.

First Reference *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Second Reference *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Emergency Contact

Who should we notify for you if there is an emergency?

Name *

First

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

CODE OF ETHICS FOR VOLUNTEERS

As a volunteer, I realize that I am subject to a code of ethics similar to that which binds the professional in the field in which I work. I, like them, assume certain responsibilities and expect to account for what I do in terms of what is expected of me. I understand that any information that is disclosed to me while assisting the hospice is confidential. I interpret “volunteer” to mean that I have agreed to work without compensation in money. Having been accepted as a volunteer worker, I expect to do my work according to the standards set forth in the Volunteer Policies and Procedures.

DECLARATION

I hereby certify that the statements made on this application are true and correct to the best of my knowledge. I understand that, by submitting this application I authorize inquiries to be made concerning my employment, character, and public records for the 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 cli-ent information I acquire in the course of my volunteer activities with Hospice of Dickinson County.

SIGNATURE *

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