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Volunteer Application

Personal Information
First Name:
Last Name:
Address:
City:
State: Zip:
Home Phone:
Work Phone:
Cell Phone:
Email:
Background/Education

Education/Field of Study/Degrees:

Previous Work Experience:

Organizations to Which You Belong:

Previous Volunteer Experience:

Placement Information
Which counties would you like to volunteer in?
Cuyahoga
Geauga
Lake
Lorain
Medina
Portage
Summit
What type of volunteer work are you interested in?

Home Care Volunteer
(respite care, companionship, transportation, errands, etc.)

Nursing Home In-patient Volunteer
(assist with patients/families at in-patient facilities)

Bereavement Volunteer

Spiritual Care Volunteer

Attorney Volunteer

Clerical

Fund Raising
Seamstress
   
Do you have transportation available?
  Yes     No
Would you be willing to transport a patient/family?
  Yes     No     Uncertain

How much time are you able to give to Hospice Volunteer work?

  Daily    Weekly    Monthly
What days are best for you?
  Any    Mon    Tue    Wed   
Thur    Fri    Sat    Sun  
What times are best for you?
  Morning    Afternoon    Evening  
Personal Experience with Death

Have you experienced a loss in your family or of someone close to you in the past five years?

  Yes     No
If yes, please specify your relationship to the person and when they died:
 
Health

Do you have any physical or medical limitations that might affect your volunteer placement?

  Yes     No
If yes, please specify :
 
Emergency Contact

In case of an emergency, please contact:

First Name:
Last Name:
Address:
City:
State: Zip:
Relationship:
Day Phone:
Physician:
Physician Phone:
References

(Please list two references. List clergy, other volunteer administrators, employers or work associates, if applicable. Do not include family.)
First Name:
Last Name:
Address:
City:
State: Zip:
Relationship:
Day Phone:
   
First Name:
Last Name:
Address:
City:
State: zip:
Relationship:
Day Phone:
   
Why do you wish to be a Hospice volunteer?
 
   
 

 

 

  

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