Personal Information

Name

First NameLast Name

E-mail

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Preferred Method of Contact?

Desired Branch Location

Are you 18 years of age or older?

If No, Is an adult volunteering with you?

Have you ever been convicted of a crime?

If Yes, what for, when and where?

Do you have access to transportation?

Do you know a language other than English?

If Yes, please indicate

Whom may we contact in case of emergency?

First NameLast Name

Relationship

Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Emergency Contact Phone

Area CodePhone Number

Please check your areas of interest

Specify Here

Additional Comments

How did you hear about our Hospice volunteer program?

Why do you want to be a Hospice Volunteer?

Have you ever volunteered with us before?

If Yes, when/where?

Have you ever volunteered with another hospice before?

If yes, name of hospice

Rows	Did you graduate?	Diploma, degree or Cert. received
High School
College

List related professional organizations of which you are a member:

Military service history?

If Yes, branch:

Dates of services:

Rows	From	To
Date

Any qualities (skills, talents, knowledge, and experiences) you feel you can incorporate into your hospice volunteer work?

Professional License/Certifications (As Applicable)

Rows	Type	Organization or State Issued	Date Issued	Number
License/Certification 1
License/Certification 2

Please indicate approx. # of hours you would like to volunteer

Hours per week

Hours per month

Preferred Days

Preferred Times

List the names of two personal references whom you have known at least one year:

I give my permission to contact the following persons:

Rows	Name	Relationship	Address	Phone #
Reference #1
Reference #2

I understand that this application does not mean I will be accepted to the Auburn Crest Hospice volunteer program. I understand that if I am accepted into the volunteer program, that as a volunteer I am subject to follow the personnel policies and rules of Auburn Crest Hospice. I understand that not following the rules may lead to dismissal. I also understand that my I may be dismissed for giving incorrect information on this application.

I voluntarily give Auburn Crest Hospice the right to make an investigation into information provided on this application including but not limited to my employment history, character and public records for the purpose of determining my suitability as a volunteer. I agree to cooperate in the investigation and release from all liability or responsibility all persons, companies or corporations supplying information. I consent to take a post-hire physical examination and such future physical examinations as may be required by Auburn Crest Hospice, if requested.

I understand that Auburn Crest Hospice is a drug-free workplace and reserves the right to test for illegal drug use.

I understand that any information that is disclosed to me while volunteering for Auburn Crest is strictly confidential.

I also recognize that, to protect its clients, Auburn Crest Hospice reserves the right to terminate my Volunteer Agreement at any time for any reason, and that is Auburn Crest’s policy to do so if I am unable to pass the fingerprint background check that is part of the mandatory volunteer orientation.

I interpret “volunteer” to mean that I have agreed to work without compensation in money. I understand that by submitting this application I agree that I am volunteering my service and agree to do my work according to the standards set forth in the Volunteer Policies and Procedures.

Applicant Signature

Date

MonthDayYear

Personal Information

Identified Areas of Interest

Educational/Special Training/Work History

Availability

References

Volunteer Agreement