Volunteer Application- Apply now!

Address Line 1 (Required)(Required)

Address Line 2

City(Required)

State(Required)

Zip(Required)

Email(Required)

Home Phone

Mobile Phone

Employer

Occupation

Preferred Location to Volunteer(Required)

Do you speak a language other than English?(Required)

If yes, what language(s)?

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)

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

Hidden

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)

What special gifts/talents can you share with us?

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)

What days/times of the week would you be available to volunteer?

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."

Are you over 18 years of age?(Required)

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.

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.

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.

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.

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.

Date

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