Volunteer Application Name* First Last Are You 18 years old?*YesNoBirthday* MM slash DD slash YYYY Phone (Home)Phone (Mobile)*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Employer Occupation School/Work Hours Briefly describe the type of work you do:Total number of hours per week you could be available for hospice volunteering:DaytimeEveningsWeekendsOtherLevel of Education:* High School 2 Year College 4 Year College Postgraduate Foreign languages spoken: Religious Affiliation: Catholic Protestant Jewish None Other (Optional—this assists us in proper placement of our volunteers. We serve patients regardless of religious affiliation)Personal InformationHow did you hear about us? Why do you wish to be involved in hospice?What organizations or clubs do you belong to?Have you had experience with the terminally ill? Yes No Has someone close to you died within the past year? Yes No Do you have available transportation for your volunteer work? Yes No Do you have a valid California driver’s license ? Yes No Do you have automobile liability insurance? Yes No (Auto insurance is required if you use your car for hospice work)Have you been convicted of a felony within the last 7 years? Yes No (Conviction will not necessarily disqualify you from volunteering.) What do you like about yourself?List experiences you believe would be helpful to you in hospice volunteering, i.e., schooling, work, volunteer experience, office skills, arts and crafts, etc.Areas of Interest (please check all that apply) Patient and/or family/visits Meal preparation Shopping/run errands Relieve primary caregiver Read to patient Homemaking chores Transportation Write letters Childcare Bereavement follow-up Direct:Areas of Interest (please check all that apply) Speakers bureau Sewing/crafts Computer work Office assistance Videotaping Music or entertaining Mass mailings Photography Host/hostess for hospice events Indirect:Personal References: (with phone numbers)Name + PhoneName + Phone Emergency Contact InformationEmergency Contact Name First Last Relationship Phone: Confirm Information & SignApplicant Signature*Date* MM slash DD slash YYYY Applicant Email* CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
