Hospice Volunteer Application

Contact Information

Date *

First Name *

Last Name *

Middle Initial

Are you over 18 years of age? *

Birth Date *

Street Address *

City *

State *

Zip Code *

Home Phone

Cell Phone *

Email *

What is the preferred method of contact? *

In case of emergency, who should we notify? (name, relationship, phone) *

Employment History

Employer (if applicable)

Phone

Positon / Job Title

Work Schedule (Days / Hours)

Describe the type of work you do.

Have you ever worked for Well Care Health? *

If yes, please detail:

Volunteer Ability, Education, History

Have you ever volunteered for Well Care Hospice? *

If yes, please give details:

Total Number of Hours per week you could be available for hospice volunteering:

Daytime

Evenings

Weekend

Other

Education: (List those items which you believe could be helpful to you in hospice, i.e. schooling, work, lay experience, office skills, arts and crafts)

Have you ever done any volunteer work? *

If yes, please give details:

Are you a Veteran? *

If yes, what branch of the military

Why Volunteer for Hospice?

How did you hear about Hospice?

Why do you wish to volunteer for Hospice?

Have you had experience with terminally ill people? *

If yes, please give details:

What strengths can you bring to Well Care Hospice?

Do you speak a foreign language?

Do you have reliable transportation?

Preferred Type of Volunteer Work: *

If you are interested in providing your professional services, please provide your professional field and license/certification information:

Professional Field

License/Certification:

All volunteers are required to complete 12 hours of volunteer training. Volunteers with a license/certification will be required to complete additional competencies associated with their profession.

References

Please provide the name, complete mailing address and phone number of two professional or personal references. Family members are NOT an acceptable reference.

Reference #1

Name (first,last,MI) *

Relationship *

Street Address *

City *

State *

Zip Code *

Phone *

Email *

Reference #2

Name (first,last,MI) *

Relationship *

Street Address *

City *

State *

Zip Code *

Phone *

Email *

Background

Have you ever been charged and/or convicted of abusing, neglecting or mistreating patients or of misappropriating patient’s property in this state or in any other state? *

If yes, please describe the offense, the date of the conviction and the underlying circumstances.

Have you ever been convicted of (1) felony, (2) cruelty to persons, or (3) assault of a victim sixty years of age or older? *

If yes, please describe the offense, the date of the conviction and the underlying circumstances.

I hereby certify that I have not been convicted and/or found guilty of patient abuse, neglect, or mistreatment, or misappropriation of patient property in this state or in any state and that I am not listed in any resident or patient abuse registry in this state or in any other state. I understand that any offer to become a volunteer by Well Care Hospice is conditional upon verification of this information with the state patient abuse registry and that a listing on such a registry or registries of any other state may act as an automatic withdrawal of any such offer to become a volunteer.” I understand that Well Care Hospice requires a thorough background investigation for ALL potential volunteers. This investigation is limited to only that information required to determine fitness for volunteering and may include but is not limited to past employment history verification, job performance, disciplinary record, financial/credit history, and a criminal background investigation. By affixing my signature to this document, I agree to hold harmless any previous employer, agent of that corporation, or any individual or organization providing information pursuant to this Authorization.

Signature of Applicant/Guardian (if less than 18 years old) *

Social Security Number *

Signature & Agreement

I hereby certify that I have not been convicted and/or found guilty of patient abuse, neglect, or mistreatment, or misappropriation of patient property in this state or in any state and that I am not listed in any resident or patient abuse registry in this state or in any other state. I understand that any offer to become a volunteer by Well Care Hospice is conditional upon verification of this information with the state patient abuse registry and that a listing on such a registry or registries of any other state may act as an automatic withdrawal of any such offer to become a volunteer.” I understand that Well Care Hospice requires a thorough background investigation for ALL potential volunteers. This investigation is limited to only that information required to determine fitness for volunteering and may include but is not limited to past employment history verification, job performance, disciplinary record, financial/credit history, and a criminal background investigation. By affixing my signature to this document, I agree to hold harmless any previous employer, agent of that corporation, or any individual or organization providing information pursuant to this Authorization.

Signature of Applicant *

Date *

Signature of Guardian (if less than 18 years old)

Date

Thank you for your volunteer application to Well Care Health. It has been sent.

There was an error trying to send your volunteer application to Well Care Health. Please try again later.

Give the gift of your time.

Become A Well Care Hospice Volunteer

Contact Information

Employment History

Volunteer Ability, Education, History

Why Volunteer for Hospice?

All volunteers are required to complete 12 hours of volunteer training. Volunteers with a license/certification will be required to complete additional competencies associated with their profession.

References

Reference #1

Reference #2

Background

Signature & Agreement

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