Volunteer Application Form (working with Horizon Hospice patients)

Please complete this application form if you are interested in becoming a Horizon Hospice volunteer. Once you complete the form, click the submit button at the bottom.

Contact Information

First name:

Last name:

Middle Initial:

preffered name:

Street 1:

Street 2:

Street 3:

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:

Birthday:

Area of town you reside:

Gender:

Social security number:

References

1

2

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

phone phone:

Email address:

Relationship:

Skills, Experience and Hobbies

In which of these areas do you see yourself using to connect with a hospice patient. Check ALL that apply

Availability

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

Assignment Preference

What area do you wish to volunteer in?

Your experience with loss

Tell us a bit about your personal experience with loss.

Have you experienced the loss of a love:

How comfortable are you with death.:

Occupation:

If you have experienced the death of a loved one, how did that experience affect you?

Employer

Please list your current or most recent employer.

Employer name:

Military Service

Are you a Veteran or Active Military?

If yes, specify which one and branch.

What motivated you to volunteer with us?

Additional Information

What else would you like to tell us about yourself?

Volunteer Information Center

We provide an online "Volunteer Information Center" where volunteers record their volunteer time, check their schedules, update their information, and receive messages. Please select the password you would like to use to access the online Volunteer Information Center.

Please enter a password that:

Is between 6 and 30 characters long
Contains both letters and numbers.

Password:

Confirm password:

I Agree

I understand and agree that submitting this application form does not automatically register me as a Horizon Hospice volunteer, and that there may be certain qualifications I must meet, including the acceptance into the volunteer program and 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 Agree