Volunteer Application

Volunteer Application

First and Last Name*

Email Address*

Form Date Field

Home Address*

Phone Number*

At any time, have you completed the hospice Volunteer Training Program?

Please indicate if you have completed the program*

Select or enter value

If yes: From whom did you receive your training?*

Describe your past hospice volunteer experience*

Why do you want to become a hospice volunteer?*

What other volunteer experience do you have?*

What do you consider your strongest attributes or skills that you bring to Hospice?

please describe skills and attributes below:*

What life experience do you feel will be helpful to you as a Hospice Volunteer?

Please describe your experiences below:*

Have you experience personal loss in the past year*

Select or enter value

If yes, please explain*

Work Experience*

Education*

Special Training*

Certificates/Licenses*

Interests and Hobbies?*

Besides English, do you speak any other language?*

Have you ever been convicted of a felony?*

Select or enter value

if yes, please explain the circumstances:*

Do you have an physical or health limitations?*

Religious or Spiritual Affiliation?*

Are you a member of a place of worship?*

Hospice Volunteer Opportunities:

Please review and check those in which you have interest in

You can make multiple selections*

PATIENT AND FAMILY SUPPORT VOLUNTEER: The volunteer provides support and companionship to the patient and the family.

BEREAVEMENT VOLUNTEER FOR FAMILY SUPPORT: Family Support: The volunteers provide support to the families after the death of a patient.

BEREAVEMENT VOLUNTEERS FOR TELEPHONE SUPPORT: Volunteers assist in the bereavement process by calling families after the death of the patient. The calls are to provide, reassurance, support, active listening and a friendly voice.

PHARMACY VOLUNTEERS: Pick up prescriptions from pharmacies and deliver to the patients home. The area the volunteer covers is designated by the volunteer and can usually be scheduled at a time convenient for the volunteer.

SUPPLY/ EQUIPMENT VOLUNTEERS: Pick up of supplies and small medical equipment, from the office, and delivered to the patient's home, The area covered is designated by the volunteer and can usually be scheduled at the volunteers convenience.

HOSPITAL SUPPORT AND WELCOME VOLUNTEERS: Provide support and companionship to patients who have been admitted to the hospital . Volunteers may also make visits to patients who may have been transferred to a new setting.

TRANSLATION VOLUNTEERS: Bilingual volunteers may serve as translators. The volunteer may visit a patient who speaks a language other than English. The volunteer may also translate for family members.

OUTREACH EVENT VOLUNTEERS: Assists hospice with community outreach by representing First Call Hospice at health fairs, speaking to community groups and volunteer training.

OFFICE VOLUNTEERS: Provides administrative support. Duties include filing, data entry, mailing, answering phones, assembling information packets and general office support.

References

I consent to, and authorize First Call Hospice and its personnel to contact my personal references. Please prove name address, phone number and relationship of three personal references below.

Reference #1 First and Last Name & Relationship*

Reference #1 Phone number*

Phone

Reference #1 Email*

Reference #2 First and Last Name & Relationship*

Reference #2 Phone Number*

Phone

Reference #2 Email*

Reference #3 First and Last Name & Relationship*

Reference #3 Phone Number*

Phone

Reference #3 Email*

CODE OF ETHICS FOR VOLUNTEERS:

Thank you for your interest in First Call Hospice and Palliative Care. Please read the code of ethics below:

1. Patient care volunteers will respect the lifestyle, culture, and religious orientation of patients and their families. The role of the volunteer is to provide understanding and support to patients and families during the terminal illness. It is NOT appropriate to attempt to change the lifestyle of the patient of their family. The patient's and family's wishes and needs are our primary concern and take precedence over the wishes and needs of the hospice staff and volunteers.

2. The religious / spiritual resources of the patient and family are very important elements in the Plan of Care. The hospice staff and volunteers will guard against any effort to convert the patient/family to a particular religious or spiritual orientation.

3. I interpret "volunteer" to mean that I have agreed to work without compensation in money but having been accepted as a volunteer worker, I expect to do my work accordingly to the standards set forth in the volunteer policies and procedures.

Please read below:

By typing my name below, I hereby certify that the information I have provided is true, correct and complete to the best of my knowledge. I understand that by submitting this application, I authorize inquiries to be made concerning my background and character for the purpose of determining m suitability as a volunteer. I affirm to have read the "Code of Ethics for Volunteers" and agree to abide by its regulations. I agree to respect the confidentiality of any client information I may acquire in the course of my volunteer activities.

Please type your full name*

Send me a copy of my responses

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