Hello and thank you for your interest in volunteering with Hospice of Central Ohio!

Please complete this application form; note that the fields with asterisks (*) are required.

Once you complete and submit the form, a Volunteer Services representative will review the information and contact you. Thank you!


Contact Information


Emergency Contacts

In the event of an emergency who should we notify?



Availability

Please indicate the times you are usually available to volunteer.



Volunteer Interest


Loss History/Lessons


Your Expectations


If Applicant is under the age of 18

(volunteer staff in any of our direct patient support positions must be at least 18 years of age)

I give my permission for my child to participate as a volunteer with Hospice of Central Ohio, as per the Code of Ethics stated below.



Smoking Policy

Smoking is prohibited in all facilities used by and partnered with Ohio's Hospice. To eliminate residual smoke contact for our patients and customers, all staff are prohibited from smoking, on or off the campus and must not have an odor of residual smoke, while on work time. This policy applies to all colleagues, staff, students, contracted personnel, volunteers, and vendors.



Photo/Media Release

I grant full permission to the sponsors, organizers and affiliates to use my name, photographs or any other record of participation in this volunteer service event,

for use in any broadcast, telecast, or any other written account of the event for publicity purposes, without compensation or remuneration.



Code of Ethics for Volunteers

I understand that any information that is disclosed to me while assisting Hospice of Central Ohio is confidential.

CONFIDENTIALITY:

It is the policy of Hospice of Central Ohio that all medical, financial, and personal information pertaining to a patient is confidential and is protected. This includes unauthorized viewing, discussion, and disclosure. Therefore, volunteers may look at, use, or disclose patient information ONLY as it relates to the performance of their duties. Any unauthorized viewing, discussion, or disclosure will provide grounds for immediate dismissal. Whenever it is questionable as to what information is confidential, it is the volunteer’s responsibility to discuss the matter with his/her supervisor first.

DECLARATION

I hereby certify that the statements made on this application are true and correct to the best of my knowledge. 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 agree to respect the confidentiality of any patient and/or client information I acquire in the course of my volunteer activities with Hospice of Central Ohio.

Hospice of Central Ohio retains the right to verify all information provided by me. In the process of such verification, I fully authorize OHI to contact any person, school, organization, or employer listed to disclose all information necessary to verify information or statements. I release all persons who disclose such information from any liability or damages to me or anyone acting in my name. I waive any written notice of the release of such information that may be required by any state or federal law. Any falsification, misrepresentation, or omission, whenever discovered, shall be considered legitimate and sufficient grounds for dismissal.

As required, in order to volunteer with Hospice of Central Ohio in a direct patient support role, a TB test will be performed.

Volunteering with Hospice of Central Ohio is at-will. This means that I may stop volunteering at any time. Similarly, Hospice of Central Ohio may terminate my volunteering at any time, with or without cause.

I acknowledge and have read the statements above and agree to abide by the expectations of the Volunteer Services department and Hospice of Central Ohio.