Thank you for your interest in the volunteer program at Carter Healthcare & Hospice. This Agency is an equal opportunity employer dedicated to a policy of non-discrimination on any basis, including race, color, creed, religion, age, sex, national origin, ancestry, sexual orientation, marital status, military status, including equal opportunity for disabled veterans, recently separated veterans, other protected veterans and Armed Forces Service Medal veterans, or the presence of a physical or mental medical condition or disability. 


Name and address

Emergency Contact

Availability

Please indicate the days and times you are usually available to volunteer. Our volunteer schedules can be flexible depending on patient needs. We do ask that you commit to our Volunteer Program for at least 6 months giving a few hours a week, or for a predetermined number of volunteer hours. 



Programs

Please select any or all programs you are interested in volunteering for:

***If willing to make patient visits please indicate distance you are willing to travel. (example; 30 miles from home, or 20 miles from home)



School History

Are you currently enrolled in a college, university, or technical school? If so what are your future plans?



Work History

Special Skills or Hobbies

We would love to know if you play any instruments, good with technology, speak multiple languages, or any other unique abilities. 



Volunteer History

Personal References

Please list two professional, non-related persons who we may contact:



Volunteer Statement of Agreement

As a volunteer with Carter Hospice I will adhere to all departmental procedures and will perform my volunteer duties in a manner consistent with the published policies and procedures with Carter Healthcare and Hospice. These include the following:

 I will maintain confidentiality at all times and in all places in accordance with HIPAA guidelines and Carter Healthcare. I will respect the privacy of patients and families. I understand that I will not have access to patients’ medical records. I will not be allowed to take photos or videos of patients and families. 

 I will not give medical or legal advice to patients and families, but will make appropriate referrals to The Carter Hospice staff. 

 I will treat patients, families, visitors, staff and other volunteers with dignity and respect regardless of race, religion, gender, age, national origin, disability or socioeconomic status. 

 I will refrain from sharing my personal contact information including email addresses, social media, and physical addresses whether home, work or other. 

 I will not use, possess or be under the influence of alcohol or illegal drugs nor have alcohol on my breath while volunteering at, or representing, Carter Hospice. 

 I will never discuss problems, grievances, criticisms, or suggestions in public areas nor in the presence of patients, will families and/or visitors, but rather discuss them in private with the appropriate staff member. 

 I will be dependable, punctual, and conscientious. 

 I will notify my assigned volunteer program staff member in a timely manner if I am unable to serve on my normal shift due to illness, vacation, or tardiness due to unforeseen circumstances. 

I will be responsible for my attendance and recording hours by signing in upon each shift. 

 I will be responsible for checking emails, voicemails or other forms of contact between myself and Carter Healthcare and Hospice, and will notify the department of any changes to my contact information- including phone numbers, email addresses and physical addresses. 

 I will follow appropriate dress code guidelines, be well groomed and conduct myself in a professional manner. 

 I will maintain appropriate boundaries and use other self-care strategies. 

 I am aware that Carter Healthcare and Hospice reserves the right to update, change or create policies, procedures and guidelines at any time. Once changes are implemented my signature will be required as acknowledgement of receipt. 

 I agree to make a commitment to volunteer with pre determined number of hours completed for Carter Hospice. 

 I understand that failure to comply with any of the above policies and guidelines will result in probation and/or dismissal from service as a volunteer.