Services
Home Health Services
Hospice Services
Honoring Veterans
About Us
Service Areas
Resources
Newsroom
Careers
Online Bill Pay
Search
Menu
Menu
Volunteer Application
Step
1
of
6
16%
Name
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
This field is hidden when viewing the form
Address Line 1 (Deprecated)
This field is hidden when viewing the form
Address Line 2 (Deprecated)
This field is hidden when viewing the form
City (Deprecated)
This field is hidden when viewing the form
State (Deprecated)
This field is hidden when viewing the form
Zip (Deprecated)
Email
(Required)
Home Phone
Mobile Phone
Employer
Occupation
Preferred Location to Volunteer
(Required)
Select One
Saraland, Alabama
Hammond, Louisiana
Batesville, Mississippi
Corinth, Mississippi
Flowood, Mississippi
Tupelo, Mississippi
Wiggins, Mississippi
Tyler, Texas
Do you speak a language other than English?
(Required)
Select One
Yes
No
If yes, what language(s)?
Can you speak, read, and write in the language(s) indicated? (Select all that apply)
Speak
Read
Write
Select All
Have you suffered a loss within the last year? (Death, Job, Relationship, Relocation, Physical/Health)?
Health/Physical considerations impacting volunteer assignments (allergies; smoke-free environments; mobility considerations such as stairs, distances; night driving, etc):
Have you ever been convicted of a crime?
(Required)
Select One
Yes
No
If yes, please describe:
Why do you want to become a Hospice Volunteer?
(Required)
Emergency Contact Information
First/Last Name:
(Required)
Relationship
Home Phone
Mobile Phone
Email Address
Volunteer Experience
Prior Volunteer Experience:
Name of Agency/Organization, Location(s), and Dates of Service
This field is hidden when viewing the form
Professional/Academic/Civic Affiliations
Religious Affiliation (Optional)
References
Please provide information for two professional or personal references who are not related to you.
Reference 1: First/Last Name
(Required)
Reference 1: Phone
(Required)
Reference 1: Email address
(Required)
Reference 1: Relationship
(Required)
Reference 2: First/Last Name
(Required)
Reference 2: Phone
(Required)
Reference 2: Email address
(Required)
Reference 2: Relationship
(Required)
About You
What special gifts/talents can you share with us?
Listed below are some of our VitalCaring volunteer activities. Please check all that interest you:
(Required)
Companionship/Reading
Light Housekeeping
Simple Food Preparation
Light Yardwork
Prepare Holiday Treats
Administrative Assistance
Coordinate Annual Volunteer Recognition Luncheon/Dinner
Personal Thank-you Notes to Volunteers
Phone Calls to Patient/Primary Care Giver
Letter Writing/Email
Errands for Patient/Primary Care Giver
Assist Chaplain with Service of Remembrance
Photography
Arts & Crafts
Public Speaking
If applicable, please list any additional activities you are interested in that are not included in the list above:
Do you have access to transportation?
(Required)
Select One
Yes
No
What days/times of the week would you be available to volunteer?
Acknowledgements
Publicity Release
(Required)
At times, information concerning a volunteer may be used in a press release or other reasons deemed appropriate by VitalCaring Hospice. Submission of this application provides consent for VitalCaring to use the volunteer’s name, title, portrait, picture, video image, photograph, or any reproduction likeness or quotation of the volunteer’s remarks for public information or other organizational programs. If you accept, select "yes."
Select One
Yes
No
Are you over 18 years of age?
(Required)
Select One
Yes
No
Applicant Acknowledgement (Over 18 years of Age)
(Required)
Please read the following statements and sign below: Universal Precautions taken by medical personnel when working with all patients and Infection Control are taught during volunteer training. All patient information is confidential. This documentation becomes part of the medical record which is an integral part of the VitalCaring Hospice plan of care for the patient and facilitates government funding. If you accept, select "yes," and provide your printed signature below.
Select One
Yes
No
Applicant (Print Signature):
(Required)
First
Last
Tuberculosis (TB) Testing Consent
(Required)
All new volunteers with VitalCaring must be administered two TB tests prior to working with patients. These tests are available at no charge. The first test is administered during volunteer training with results evaluated on the second day following the test. The second test is administered two weeks after the first. Your signature below authorizes VitalCaring to administer the required TB Screening.
Yes
No
Parent/Guardian Acknowledgement
(Required)
Please read the following statements below with your teen volunteer applicant and sign below: Teens under 18 years old are not allowed to transport patients or their family members by auto. Universal Precautions taken by medical personnel when working with all patients and Infection Control are taught during volunteer training. All patient information is confidential. Since your child may share information with you concerning their volunteer experience, your signature below indicates that you will keep in confidence any information shared with you about a VitalCaring patient. All teen volunteers must document each visit with patient/family. This documentation becomes part of the medical record which is an integral part of the VitalCaring Hospice plan of care for the patient and facilitates government funding. If you accept, select "yes," and provide your printed signature below.
Yes
No
Parent/Guardian Name (Print Signature):
(Required)
First
Last
Tuberculosis (TB) Testing Consent for Teen Volunteers:
(Required)
All new volunteers with VitalCaring must be administered two TB tests prior to working with patients. These tests are available at no charge. The first test is administered during volunteer training with results evaluated on the second day following the test. The second test is administered two weeks after the first. Your signature below authorizes VitalCaring to administer the required TB Screening for your teen. VitalCaring has my permission to administer required TB Screening for my child. If you accept, select "yes," and provide your printed signature below.
Select One
Yes
No
Parent/Guardian Name (Print Signature):
(Required)
First
Last
Signatures and Authorization
I certify that all information I have provided is true, complete and correct and understand this application and any other documents obtained through the application process will remain confidential within the VitalCaring Volunteer Services program. I expressly authorize, without reservation, VitalCaring, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and education institutions and to otherwise verify the accuracy of all information provided by me in the application. I hereby waive any and all rights and claims I may have regarding VitalCaring, its agents, employees and representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the volunteer process and all other persons, corporations or organizations for furnishing such information about me. I understand that VitalCaring does not lawfully discriminate and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for volunteering on any basis prohibited by applicable local, state or federal law. I understand that all volunteers represent VitalCaring and are subject to the rules and regulations of the organization, including volunteer training, background checks, fingerprinting, Tuberculosis (TB) testing and a health screening, and that at any time I may be subject to random drug testing.
Untitled
(Required)
I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for volunteering or (ii) may result in my immediate discharge from VitalCaring whenever it is discovered.
Select One
Yes
No
Signature Confirmation of above Signatures & Authorization Statement
Do not sign until you have read the above statement. I certify that I have read, fully understand and accept all terms of the foregoing application statement.
First
Last
Date
MM slash DD slash YYYY
CAPTCHA
Section Break
Scroll to top
