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VOLUNTEER APPLICATION

General Information

Name:

Address: City: State: Zip:

Work Phone: Home Phone: Cell/Pager:

E-Mail Address:

Do you have a reliable vehicle? Yes No

Do you have liability insurance? Yes No

Employment Work History

:

:

If not currently working, do you plan to begin working in the near future? Yes No

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

Employer #1:



Education

Currently attending school: Yes No Full-time Part-time

: :

Do you have future schooling plans: Yes

Personal References

Name Address Phone







Emergency Contacts
Name Relationship Phone

Relevant Background

Have you experienced any deaths in your family or of those close to you? Yes No



Health Status

Describe your health: Good Fair Poor

Yes No

Do you have any physical or medical restrictions, which might prevent you from performing certain activities? Yes No

Do you have immediate family members who are terminally ill? Yes No

Have you ever had cancer? Yes in the past Yes, currently in treatment No

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

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

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.