Volunteer Service Application
Hospice of Davidson County, Inc.
Volunteer Service Application
Equal Opportunity Employer
Date:
Last Name:
First Name:
Middle/Maiden Name:
Address:
City:
State
Zip:
E-Mail:
Drivers License #:
Social Security #:
Home Phone:
Business Phone:
Cell Phone:
Volunteer Information
Emergency Contact
Name:
Relationship:
Phone Number:
Volunteer Experience
Please list previous volunteer experience (organization, location, dates, hours served, and what you did.
List organizations, churches, or clubs in which you are active.
Education/Specialty Training
I have completed:
Degree/Major/Certifications:
Special Services/Alternative Therapies:
Do you know a language other than English?
Language?
Language?
Employer Information
Employer:
Position:
Can you receive calls at work?
Brief Work Experience:
Areas of Interest/Availability
Patient Family Care
Bereavement:
Non-Patient Services:
List any other experience or skills related to your volunteer interests:
I would be able to volunteer:
Are you available on short notice?
Beginning?
Do you have transportation?
Have you experienced the loss of a loved one during the past year?
If yes, what was your relationship to the deceased?
References
Provide 3 personal references (excluding family members)
Name:
Phone:
Address:
Name:
Phone:
Address:
Name:
Phone:
Address:
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 doin 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 Volunteer Policies and Procedures.
I understand that my acceptance as a volunteer is contingent upon the successful completion of my
references, criminal background / sex offender investigation, and pre-volunteer drug screen.
I understand volunteers must attend a volunteer workshop requiring 12 hours and that ACHC Licensure
requires 12 hours of continuing education annually. I understand that I must also submit to a TB test prior
to volunteering.
Signature:
Date:
Questions? 1-800-768-4677
Volunteer Application may be submitted by mail or fax to:
Hospice of Davidson County
200 Hospice Way
Lexington, NC 27292
FAX: 336-474-2081
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 inquire to be made concerning my employment, character and public records for the purpose of determining my suitability as a volunteer
Signature:
Date:
