Volunteer Application Form

Applicants must have a valid U.S. social security number and driver’s license or state ID.

Contact Information

First name:

Last name:

Middle name:

Title:

Nickname:

Street 1:

Street 2:

City:

State:

* Zip: *

Preferred phone:

Alternate phone:

Email address:

Email Preferences

Email provides us with the most efficient means of communicating updates, opportunities, and agency news to our team of volunteers. May we add you to our email distribution list?

Email Permission:

Other Information

Date of birth:

Animal Allergies:

Are you a veteran or active duty?:

If yes, branch of service:

Driver's License/State ID #:

Driver's License State:

Have you been convicted of a felony?:

Occupation (list previous, if retired):

* Referral Source:

Volunteer Preferences

Availability

Please indicate the days and times you are usually available to volunteer.

Skills Section

Please select all applicable skills.

Emergency Contact Information

First name:

Last name:

Primary phone:

Relationship:

Why Volunteer

Why would you like to volunteer with Mission Hospice?

Related Work and/or Experience

Please describe any work or other experiences which you feel have prepared you to be a volunteer.

Personal Characteristics

What personal characteristics will allow you to best carry out your role as a volunteer?

Previous Experiences with Death and Dying

When was the last death you were impacted by? What was the relationship?

Applicants that have experienced the recent death of a loved one are encouraged to wait one year before volunteering with hospice patients.

Electronic Signature/Certification

I certify that I am submitting a COMPLETE application and that the information contained in this application is correct to the best of my knowledge.

I understand that I will be required to provide two reference forms to individuals who know me on a personal or professional basis. By checking this box, I am authorizing Mission Hospice to contact my references regarding my appropriateness as a volunteer.

I Agree