Name

Birth date

Address

City and Zip code

Prior address if less than 5 years:

City and Zip code

Phone(s) - Home, Work, and Cell

Email Address

Are you currently a student? Are you currently a student? Yes No

If yes, at what school are you currently enrolled?

Are you currently employed? Are you currently employed? Yes No Full Time Part Time

Employment History (List: Where, Dates, and Duties

What Volunteer experiences have you had?

Please describe your educational experiences (i.e. schools, colleges, degrees, technical training):

What do you like to do for personal interest, hobbies, and activities?

Have you experienced a loss or major lifestyle change in the last year? Have you experienced a loss or major lifestyle change in the last year? Yes No

If you have experience a loss or major lifestyle change in the last year, please elaborate:

Please list any training or classes you have attended on death, dying, and/or bereavement (including Hospice Volunteer Training):

What personal or professional experiences have you had with the terminally ill or dying process?

What are your sources of emotional support?

Do those people close to you support your decision to be a hospice volunteer? Do those people close to you support your decision to be a hospice volunteer? Yes No

What is your understanding of Hospice Care and the role of the Hospice Volunteer?

What is your motivation for becoming a Hospice Volunteer at this time?

What is the relationship, if any, between your spiritual beliefs and your interest in being a Hospice Volunteer?

What is your regular source of transportation?

Do you have a valid driver's license? Do you have a valid driver's license? Yes No

Driver's License Number

Do you have Current Auto insurance? Do you have Current Auto insurance? Yes No

Have you ever been convicted of a felony? Have you ever been convicted of a felony? Yes No

Do you speak any language other than English? Do you speak any language other than English? Yes No

If yes, what other languages?

How many hours per week would you be interested in volunteering? (Average)

Times available for Volunteer work: Times available for Volunteer work: Days Evenings Weekends Varied

Type of Volunteer work preferred: Type of Volunteer work preferred: Patient/Family Bereavement Office Support Assisted Pet Therapy On-call errands or transportation Others

What type of volunteer work preferred, beyond those listed above

Is there any additional information about yourself that you would like to share regarding your interest in Hospice or your ability to be a Hospice Volunteer?

Character reference 1 (not related to Hospice program affiliation) Name

Reference 1 Address

Reference 1 City and Zip

Reference 1 Relationship to you

Reference 1 Phone number

Character reference 2 (not related to Hospice program affiliation) Name

Reference 2 Address

Reference 2 City and Zip

Reference 2 Relationship to you

Reference 2 Phone number

Character reference 3 (not related to Hospice program affiliation) Name

Reference 3 Address

Reference 3 City and Zip

Reference 3 Relationship to you

Reference 3 Phone number

Other