Bakersfield Volunteer Application

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Bakersfield Volunteer Application

Please fill out the volunteer application as completely as possible.

Name

Address

City

State

Zip Code

Work Phone

Home Phone

Cell Phone or Pager

Email Address

Do you have a reliable vehicle?

Do you have liability insurance?

Current Employer:

Job Description:

Days and hours per week:

If not currently working, do you plan to begin working in the near future?

If yes, explain:

Excluding your current job, list the two most recent positions held:

Employer #1:

Responsibilities:

Employer #2:

Responsibilities:

Education

Currently attending school:

College attended:

Year graduated:

Do you have future schooling plans:

Personal References

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

Emergency Contacts

Name

Relationship

Phone

Name

Relationship

Phone

Relevant Background

Have you had a personal experience with terminal illness or death within your immediate family in the past year? (Briefly explain):

Have you experienced any deaths in your family or of those close to you?

If yes, please specify your relationship to the person(s) and when they died:

How did you hear about Hoffmann Hospice?

Why do you want to volunteer for Hoffmann Hospice?

Have you received hospice training previously? if yes, where and when:

Health Status

Describe your health:

If poor, explain:

Have you received a Tuberculosis (TB) screening within the past year?

Do you have any physical or medical restrictions, which might prevent you from performing certain activities?

If yes, please explain:

Do you have immediate family members who are terminally ill?

Have you ever had cancer?

Areas Of Interest

Select any of the following areas of interest:
Patient/family caregiver relief
Patient's Home
Skilled Facility
Bereavement support
Massage (certified massage therapist)
Interpreting
Music
Limited transportation / run errands
Other (household duties, letter writing, child care, etc.)
Fundraising / Health Fairs / Bulk Mailings / Special Projects
Professional skills (legal, financial, pastoral)
Administrative Office/Clerical/Data Entry

List any foreign language you speak or write:

Music: Name Instrument

Professional skills (legal, financial, pastoral) Name:

Administrative Office/Clerical/Data Entry Speakers Bureau

Are you able to make a six-month to one-year commitment to Hospice volunteering? Yes No

Please list any special hobbies, talents, or services you would be willing to share:

You are about to submit personal information over the internet. While Hoffmann Hospice will make every reasonable attempt to ensure that your information is kept safe, please understand that there is an inherent risk to exchanging confidential information by any means (electronic or otherwise). By submitting this form you acknowledge that you understand and accept this risk.

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