Hospice Volunteer Application Form
Please complete this application form if you are interested in becoming a Northwest Colorado Health Hospice volunteer. Once you complete the form, click the submit button at the bottom.
Contact Information
First name:
*
Last name:
*
Title:
Choose
Dr.
Mr.
Mrs.
Ms.
Street 1:
*
Street 2:
City:
*
State:
Choose
CO
*
Zip:
*
Home phone:
OK to call me here
Work phone:
OK to call me here
Cell phone:
*
Email address:
Marital Status: Number and Ages of Children:
Demographic Information
You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.
Date of birth:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
*
Age range:
Choose
18 to 64
65 or over
Under 18
*
Gender:
Choose
Female
Male
T-Shirt size:
Choose
Extra extra Large
Extra Large
Large
Medium
Small
How did you learn about our Hospice Volunteer Program?
Educational Background
Please indicate the days and times you are usually available to volunteer.
Education:
Choose
Associate degree
College degree
Doctoral degree
High school
Masters degree
Some college
Trade/Vocational school
School:
Special Training or Skills Volunteer Experience
Email Preferences
We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email, however will not send you any email you prefer not to receive. Use the checkboxes below to select the kinds of email you would like to receive from us.
What kinds of email would you like to receive?
Electronic newsletters
Recruitment appeals
Schedule reminders
Emergency Contact Information
First name:
*
Last name:
*
Cell phone:
*
Please list an individual that we may contact in case of an emergency:
References
1
2
First name:
*
First name:
*
Last name:
*
Last name:
*
Street 1:
Street 1:
City:
City:
State:
Choose
CO
State:
Choose
CO
Zip:
Zip:
Home phone:
OK to call here
Home phone:
OK to call here
Work phone:
Work phone:
Cell phone:
*
OK to call here
Cell phone:
*
OK to call here
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Mother
Neighbor
Son
Spouse
Supervisor
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Mother
Neighbor
Son
Spouse
Supervisor
Contacted:
Choose
No
Yes
Contacted:
Choose
No
Yes
Verified:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2042
2041
2040
2039
2038
2037
2036
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
Verified:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2042
2041
2040
2039
2038
2037
2036
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
Availability
Please comment in the box below your areas of interest:
DIRECT SERVICES include:Patient and Family Visitation or Assistance,Patient and Family Respite,Child/Teen care, Other(describe):
INDIRECT SERVICES include: Administration, Fundraising, Community Education/Marketing, Child/Teen Programs, Other (describe)
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Morning:
Afternoon:
Evening:
My availability is:
Choose
Ongoing
Ongoing, except between these dates
Only between these dates
From:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
to:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
I would like to serve up to:
hours:
Choose
Daily
Monthly
One time
Weekly
Previous Employment
Employer name:
First name:
Last name:
Title:
Choose
Dr.
Mr.
Mrs.
Ms.
Street 1:
City:
State:
Choose
CO
Zip:
Work phone:
OK to call here
Cell phone:
OK to call here
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Mother
Neighbor
Son
Spouse
Supervisor
Contacted:
Choose
No
Yes
Verified:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2042
2041
2040
2039
2038
2037
2036
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
What other types of work have you done? Do you speak a foreign language?
Religious Preference
Please explain any significant losses you have experienced, their relationship to you,how long ago the loss occurred, and how it has affected you. Please also share your thoughts about life, death and dying:
Special Needs
Do you have any special needs or physical limitations that require consideration in any volunteer placement?
Valid Drivers License/Proof of Insurance
Do you own a car? Is it a 4-wheel drive?
Are you willing to provide transportation?
Do you have proof of a valid Colorado Driver's License and auto insurance?
Convictions/Crimes
Have you ever been charged or convicted of a crime, including child neglect or abuse? If yes, please explain.
Please list any convictions or crimes in the last 7 years.
Please list any convictions or crimes in the last 7 years.
Commitment Form
I certify that all information provided in this Hospice Volunteer Application is true and complete. I understand that any false information or omission may disqualify me from further consideration from volunteering and may result in my dismissal if discovered at a later date.
As a trained Hospice Volunteer, I am willing to make a one- year commitment with Northwest Colorado Health.
I Agree
Continue