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:

Street 1:

Street 2:

City:

State:

* 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:

Age range:

Gender:

T-Shirt size:

How did you learn about our Hospice Volunteer Program?

Educational Background

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

Education:

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:

Last name:

Street 1:

City:

State:

Zip:

Home phone:

OK to call here

Home phone:

OK to call here

Work phone:

Cell phone:

* OK to call here

Cell phone:

* OK to call here

Relationship:

Contacted:

Verified:

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)

Previous Employment

Employer name:

First name:

Last name:

Title:

Street 1:

City:

State:

Zip:

Work phone:

OK to call here

Cell phone:

OK to call here

Relationship:

Contacted:

Verified:

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

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