Carle Foundation Hospital Hospice Volunteer Application
Please complete this application form if you are interested in becoming a Hospice volunteer for Carle Foundation Hospital in Urbana.
Once you complete the form, click the submit button at the bottom.
Name and address
First name:
*
Last name:
*
Middle name:
Title:
Choose
Dr.
Miss
Mr.
Mrs.
Ms.
NP
PA
Rev.
RN
Street 1:
*
Street 2:
Publishing Permission:
City:
*
State:
Choose
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
*
Zip:
*
County:
Choose
Champaign
Clark
Clay
Coles
Crawford
Cumberland
Dewitt
Douglas
Edgar
Edwards
Effingham
Ford
Hamilton
Iroquois
Jasper
Lawrence
Livingston
Macon
McLean
Moultrie
Piatt
Richland
Shelby
Vermilion
Wabash
Wayne
White
*
Home phone:
Cell phone:
Email address:
How did you find out about Hospice Volunteering?
Please enter information about how you found out about volunteering in Hospice (i.e. Website, Friend Referral, Health or Volunteer Fair or other)
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
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31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
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2007
2006
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2003
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
(year optional)
Education:
Choose
Associate degree
College degree
Doctoral degree
High school
Masters degree
Some college
Trade/Vocational school
School:
Special Skills and Hobbies
What kinds of special skills or hobbies do you have that you might use as a Hospice volunteer?
Previous Volunteer Experience
Please describe any previous volunteer experiences that you have had.
Personal Experience
What kind of work do you find enjoyable? Do you find any tasks to be frustrating, discouraging or stressful?
References
Please list two contacts that would serve as a personal or professional reference for you.
1
2
First name:
*
First name:
*
Last name:
*
Last name:
*
Middle name:
Middle name:
Title:
Choose
Dr.
Miss
Mr.
Mrs.
Ms.
NP
PA
Rev.
RN
*
Title:
Choose
Dr.
Miss
Mr.
Mrs.
Ms.
NP
PA
Rev.
RN
*
Street 1:
Street 1:
Street 2:
Street 2:
City:
City:
State:
Choose
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
State:
Choose
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
Zip:
Home phone:
Home phone:
Work phone:
Work phone:
Cell phone:
Cell phone:
Email address:
Email address:
Relationship:
Choose
Aunt/Uncle
Boyfriend
Brother in-law / Sister in-law
Brother-In-Law
Child
Cousin
Co-worker
Daughter
Daughter-in-law
Father
Friend
Grandchild
Grandparent
Grandson / Granddaughter
Mother
Mother-in-law
Neighbor
Nephew / Niece
Parent
Pastor
Sibling
Significant Other
Sister-in-law
Son
Son / Daughter
Son-in-law
Son-In-Law / Daughter-In-Law
Sponsor
Spouse
Supervisor
Teacher / Professor
Uncle / Aunt
Unknown
*
Relationship:
Choose
Aunt/Uncle
Boyfriend
Brother in-law / Sister in-law
Brother-In-Law
Child
Cousin
Co-worker
Daughter
Daughter-in-law
Father
Friend
Grandchild
Grandparent
Grandson / Granddaughter
Mother
Mother-in-law
Neighbor
Nephew / Niece
Parent
Pastor
Sibling
Significant Other
Sister-in-law
Son
Son / Daughter
Son-in-law
Son-In-Law / Daughter-In-Law
Sponsor
Spouse
Supervisor
Teacher / Professor
Uncle / Aunt
Unknown
*
Emergency Contact
Please enter your preferred emergency contact below. This contact information will only be used in the event of an emergency in which the volunteer is unable to provide similar information to a healthcare provider overseeing their treatment.
First name:
*
Last name:
*
Title:
Choose
Dr.
Miss
Mr.
Mrs.
Ms.
NP
PA
Rev.
RN
Street 1:
Street 2:
City:
State:
Choose
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
Home phone:
Work phone:
Cell phone:
Email address:
Relationship:
Choose
Aunt/Uncle
Boyfriend
Brother in-law / Sister in-law
Brother-In-Law
Child
Cousin
Co-worker
Daughter
Daughter-in-law
Father
Friend
Grandchild
Grandparent
Grandson / Granddaughter
Mother
Mother-in-law
Neighbor
Nephew / Niece
Parent
Pastor
Sibling
Significant Other
Sister-in-law
Son
Son / Daughter
Son-in-law
Son-In-Law / Daughter-In-Law
Sponsor
Spouse
Supervisor
Teacher / Professor
Uncle / Aunt
Unknown
*
Read the following carefully before continuing
In submitting this application for volunteering with Carle, I understand that an investigation may be made whereby information is obtained regarding my character, previous employment, general reputation, education and/or criminal history.
In consideration of review by The Carle Foundation, Subsidiaries and Affiliates, of my Volunteer Application and consideration of me for this program, I agree as follows:
1. I understand that pursuant to the Americans with Disabilities Act and other laws, I may request a reasonable accommodation in completing this Application and interview process. Contact Volunteer Services staff to request an accommodation.
2. I understand and agree that all information furnished in this application may be investigated by The Carle Foundation, Subsidiaries and Affiliates or its authorized representatives. I waive any right I may have to notice from any individuals or organizations named or referred to in this application prior to the release of any information to The Carle Foundation, Subsidiaries and Affiliates. I hereby authorize all individuals in organizations named or referred to in this application and any law enforcement organization to give The Carle Foundation, Subsidiaries and Affiliates all information that relates to or is requested during an investigation, and I hereby release those individuals, organizations and The Carle Foundation, Subsidiaries and Affiliates from any and all liability for any claim or damage resulting therefrom.
3. If offered a volunteer role, I understand that such offer may be contingent on passing a medical examination, the purpose of which is to determine my ability to perform the essential functions of my volunteer role. I authorize The Carle Foundation and its Subsidiaries and Affiliates to conduct an investigation as to my medical history and I authorize any medical institution to release any medical information including, but not limited to, medical records which may be necessary to determine my ability to perform the essential functions of my volunteer role.
4. I understand that The Carle Foundation, Subsidiaries and Affiliates are not obligated to provide acceptance into this program and that I am not obligated to accept a volunteer position. Nothing in this application, or in any prior or subsequent oral or written statement or communication, is intended to create any contract of employment or to create any rights in the nature of a contract. This application does not bind either party for a specific period of time regarding a volunteer position. If accepted, I understand that nothing shall restrict my right as a volunteer or the right of The Carle Foundation, Subsidiaries of Affiliates to terminate my position as a volunteer at any time for any reason.
5. I understand that, if accepted, I am required to abide by all the rules and regulations of The Carle Foundation, Subsidiaries and Affiliates and to comply with all the policies and procedures in the employee handbook, volunteer manual, any policy or procedure manual, or other communications to volunteers. I further understand that policies and procedures of The Carle Foundation and all subsidiaries and affiliates and all employment terms and conditions are subject to modifications without notice.
6. The information contained in this application is accurate and complete to the best of my knowledge and belief.
Checking this box below shall have the same force and effect as my written signature.
I Agree
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