VOLUNTEER APPLICATION Please enable JavaScript in your browser to complete this form. - Step 1 of 2Name *FirstLastSS NumberContact Number *Email *Employment InformationCURRENT EMPLOYER *ResponsibilitiesHow Long Have You Been Here?PhonePREVIOUS EMPLOYERResponsibilitiesDuration of EmploymentPhonePrevious Volunteer ExperienceName of Organization 1ResponsibilitiesDurationPhoneSupervisorName of Organization 1ResponsibilitiesDurationPhoneSupervisorEducationFormal Education *(Highest Level Completed)Do you have a current & active professional license/certificate? *YesNoIf yes, please describeExpirationDo you speak a foreign language? *If yes, which language(s)?Are you involved in any Community Activities? *(If yes, please describe)Do you drive? *YesNoDo you have regular access to an automobile? *YesNoWhat are your reasons for wanting to be a hospice volunteer? *Briefly explain your understanding of hospice care *Skills & TalentsI have the following experience, skills, or expertise and am interested in volunteering in these areas of service *Typing/Word ProcessingData EntryBillingPhonesFilingBakingSewingCraftsChild CareReadingPublic SpeakingEducationHouse CleaningLawn CarePet CareCounselingHealthcareComputerWritingHair CareCarpentryHome RepairCompanionshipTranslationSpiritual CounselorSocial ServicesBereavementPublic RelationsOther SkillsNextAvailabilityIndicate days and times you are most likely able to volunteer: *Any TimeDuring The DayDuring The NightMondayTuesdayWednesdayThursdayFridaySaturdaySundayGeographic Area *Can you be called at your job?YesNoCommentsReferencesList three references who know you well, other than relatives, preferably people for or with whom you have worked, volunteered for, or worked on a community/organizational project with.Name of Reference 1RelationshipContact InformationName of Reference 2RelationshipContact InformationName of Reference 3RelationshipContact InformationConsentI attest that all the information that I have provided on this application is true and correct to the best of my knowledge. I understand that if any of the information provided is discovered to be false, I will not be eligible for volunteer work with Alinea Family Hospice Care. I understand that I am required to provide a copy of my Driver’s License, Social Security Card, and Professional License (if applicable). I have been informed that although I am applying for a volunteer position, my personnel file will be maintained by Human Resources and similar to an employee file. I understand and consent to the following verifications and background checks that are required: *Criminal HistoryFederal OIGState OIGDL Eligibility CheckLicense/Certification VerificationSignatureI understand that before I am allowed unsupervised patient contact, I will be required to complete all necessary orientations, training, and competency checks. I also understand that I will be periodically reviewed by the Volunteer Coordinator for satisfactory job performance that meets with all State, Federal and Accreditation requirements.I understand that I will be expected to participate in hospice educational inservices. If I am not available on the day of presentation, I understand that I am responsible for following up with the educational material presented.Signature *Clear SignatureCommentSubmit
