Volunteer Application Form
 

Open Arms Hospice Volunteer Application

(* denotes required information)  

Personal Information
* Name  
* Street Address  
* City  
* State  
* Zip Code  
Birthdate  

Phone/Fax/Email
* Home Phone  
Work Phone  
Cell Phone  
Fax  
Email Address  

Employment Information
Employer  
Job Title  

Family Information
Marital Status  
Spouse's Name  
Children  
(names and ages)  

Skills and Hobbies
Interests,  
hobbies,  
skills  
Foreign languages  
you speak  

Volunteer Information
* Do you have reliable transportation? yes  no

Areas of volunteer service that interest you:
(check all that apply)
patient support
office support
bereavement support
bakery team
special events
watchman
speakers bureau

Preferred geographic area to volunteer in:

Approximate hours available each week:

Past bereavements (include relationships and dates):

How did you hear about the volunteer opportunities
with St. Francis Hospice?

Why do you want to be a St. Francis Hospice volunteer?

Volunteer Experience
Organization Name  
Beginning Date  
Ending Date  
Duties Performed
 
Organization Name  
Beginning Date  
Ending Date  
Duties Performed
 
Organization Name  
Beginning Date  
Ending Date  

Duties Performed

Medical Information
* Physician's Name  
* Street Address  
* City  
* State     * Zip Code  

Physical limitations:

Medical concerns:
 
Personal Reference #1
* Name  
* Street Address  
* City  
* State  
* Zip Code  
* Phone Number  
* Relationship  
 
Personal Reference #2
* Name  
* Street Address  
* City  
* State  
* Zip Code  
* Phone Number  
* Relationship  
 
Personal Reference #3
* Name  
* Street Address  
* City  
* State  
* Zip Code  
* Phone Number  
* Relationship  
 
Emergency Notification
Notify in case of emergency:
* Name  
* Phone Number  

I authorize St. Francis Hospice to make inquiries of my personal, employment history, and obtain a medical clearance form completed by my physician. I hereby release employers, schools, or persons from all liability in responding to inquiries in connection with this application.

I also authorize St. Francis Hospital Hospice to conduct a background check on me according to the Pre-Employment Background Checks policy. I understand that my volunteer work may not begin until satisfactory background information has been received. I also understand that St. Francis Hospital Hospice will assume all costs of this background research.

I understand that confidentiality must be maintained by every hospital employee and volunteer. Under no circumstances may information concerning patients and their families be repeated to anyone except those authorized to receive such information.

I agree to abide by the policies and procedures of St. Francis Hospice.

* I agree with the above statements.

 


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