Owatonna/Faribault Area Hospice Volunteer Application Form

Thank you for your interest in volunteering with the Hospice Program. Once you complete the form, click the submit button at the bottom. A coordinator will then contact you. All items marked with a * must be completed.

Contact Information

Please include a middle name for the completion of the background check. If you do not have a middle name please enter NMN. Also, please enter a local address and a phone number where you can be reached during business hours.

First name:

Last name:

Middle name:

Title:

Nickname:

Street 1:

City:

State:

* Zip: *

Home phone:

OK to call me here

Work phone:

OK to call me here

Cell phone:

OK to call me here

Email address:

Have you had a member of your family die within the past twelve months and what was your relationship to the individual?

References

Please include two, non-family references. We will contact them as part of determining your suitability as a volunteer in our program.

1

2

First name:

Last name:

Street 1:

City:

State:

Zip:

Cell phone:

Other phone:

Do you have any special skills that you can use in volunteering?

Demographics

*Your birth date and gender are required for the criminal background check. You may optionally provide the other information.

Date of birth:

Gender:

Other language:

What hospice or caregiving experiences have you had?

Availability

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

Emergency Contact

In the event of an emergency whom should we notify?

First name:

Last name:

Title:

Street 1:

City:

State:

Zip:

Home phone:

* OK to call here

Work phone:

OK to call here

Cell phone:

OK to call here

Relationship:

Volunteer Preferences

Please list your volunteer preferences; Patient 1:1,special events. Homestead House only: baking/cooking, delivery/errands, office, hospitality,laundry.

Area Preference

If you would like to visit patients are you willing to drive a distance? We serve patients in Owatonna, Waseca, Faribault, Northfield, Blooming Prairie, Kenyon and surrounding communities. Please list the areas where you are willing to drive:

Criminal Background Check

Please include your driver's license or state ID for the criminal background check.

This should be a letter followed by 12 numbers.

Please include your driver's license or State ID for the criminal badground check. Also, please include any alias you may have used (i.e. maiden name)

Code of Ethics

As a volunteer, I realize that I am subject to a code of ethics similar to that which binds the professional in the field in which I work. I, like them, assume certain responsiblities and expect to account for what I do in terms of what is expected of me. I understand that any information that is disclosed to me while assisting Allina Hospice patients is confidential. I interpret "volunteer" to mean that I have agreed to work without compensation of money. If and when I'm accepted as a volunteer worker, I expect to do my work according to the standards set forth in the Volunteer Policies and Procedures.

I Agree

I understand and agree that submitting this application form does not automatically register me as a Allina Health Homecare Services - Owatonna Area Hospice volunteer, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering.

By submitting this form, I attest that the information I have provided on the form is true and accurate. I understand that by submitting this application I authorize inquiries to be made concerning my employment, character and public records for the purpose of determining my suitability as a volunteer. I understand that I will undergo a criminal background check paid for by Allina. I understand if I have patient contact I will recieive a one time immunization assessment provided by Allina Health. I affirm that I have read the Volunteer Code of Ethics and agree to abide by its regulation. I agree to respect the confidentiality of any client information I acquire in the course of my volunteer activities with Hospice.

I Agree