Hospice Volunteer Application

Name

Address

Marital Status

Single

Married Enter Spouse's Name

Divorced

Separated

Widowed

Date of Birth

Home Phone

Cell Phone

Work Phone

Emergency Contact Person

Education and Special Training

Military Service

Place of Employment

Work Experience Relevant to Hospice

Volunteer Activities

Club Activities

Church Affiliation

Hobbies and Interests

When are you able to volunteer?

Sunday Monday Tuesday Wednesday
Thursday Friday Saturday

I'm available to volunteer evenings

Hours Available to Volunteer

Date you are available to start?

Please list two professional or personal references (employer, minister, supervisor, etc.)

Identified Areas of Interest

Patient and Family Care

In Home In Facility Transportation
Personal Care Meal Delivery Alternative Therapies

Bereavement

Caller Home Visits Support Group Co-Facilitator
Transportation Office and Clerical Memorial Service Committee

Non-Patient Services

Clerical Fundraising Mailings
Events Marketing Data Entry

Do you know a language other than English?

Yes Enter Language No

Other Special Services

Do you have access to transportation?

Yes No

How did you hear about our hospice volunteer program?

Why do you want to be a hospice volunteer?

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

Do you smoke?

Yes No

Does smoke bother you?

Yes No

Do pets bother you?

Yes No

Any major losses or changes in your life in the past year?

Yes Please tell me a little about them No

Do you feel that your grief in this loss has been resolved?

Yes No

How is your health? Any Limitations? Please Explain

Death and Dying

What are your thoughts and feelings about death?

Have you ever been with someone at the time of their death?

Yes If yes, please describe briefly No

Have you ever provided care to anyone who was dying?

Yes If yes, please explain No

Comments

Code of Ethics for Volunteers

As a volunteer, I realize that I am subject to a code of ethics similar to that which binds the
professional in the field in which I work. I, like them, assume certain responsibilities and expect
to account for what I do in terms of what is expected of me.

I understand that any information that is disclosed to me while assisting the hospice is confidential.

I interpret "volunteer" to mean that I have agreed to work without compensation in money. Having been accepted
as a volunteer worker, I expect to do my work according to the standards set forth in the Volunteer Policies
and Procedures.

Declaration

I hereby certify that the statements made on this application are true and correct to the best of my knowledge.
I understand that, by submitting this application, I authorize inquiries to be made concerning my employment,
character, and public records for the purpose of determining my suitability as a volunteer. I affirm that
I have read the volunteer Code of Ethics and agree to abide by its regulations. I agree to respect the
confidentiality of any client information I acquire in the course of my volunteer activities within hopsice.

By submitting this application you agree to the Code of Ethics.

Please enter your initials

Please complete the application then click the Submit button. For questions please call 770-214-2355 * — Required information

Identified Areas of Interest

Death and Dying

Code of Ethics for Volunteers

Please complete the application then click the Submit button. For questions please call 770-214-2355
* — Required information