Thank you for your interest in becoming an Alive Hospice Volunteer! Please complete this application form. All individuals 18 years or older, interested in assisting patients or working in an administrative role, will need to have a background check and motor vehicle record screening, as well as TB screening. Orientation and training will be provided. When we receive your application a Volunteer Coordinator will contact you to schedule an interview.

Contact Information

Demographics

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:

Gender:

Education:

Veteran:

Employer

Please list your current or most recent employer, if applicable.

Currently employed?:

School:

Employer:

Occupation:

Street 1:

Street 2:

Street 3:

City:

State:

Zip:

Have you ever been employed by Alive Hospice?

Experience with Loss

Describe your personal losses within the last two years. Alive Hospice encourages a waiting period of one year for those who have experienced a loss to allow for processing of grief prior to becoming a volunteer.

Interest in Volunteering

Briefly state why you are interested in volunteering for Alive Hospice.

Skills & Experience

In which of these areas do you feel you have moderate to excellent skill? Check all that apply.

Availability

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

References

Please provide two references. We contact references via email so if your reference is not comfortable using email please provide their mailing address. We kindly ask that you not provide family members as references.

1

2

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Cell phone:

Email address:

Emergency Contact

In the event of an emergency whom should we notify?

First name:

Last name:

Title:

Street 1:

Street 2:

Street 3:

City:

State:

Zip:

Home phone:

Work phone:

Cell phone:

Relationship:

I Agree

I understand and agree that submitting this application form does not automatically register me as a Alive 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 Agree