Volunteer Application Form

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!


Name and address


Emergency Contacts


Availability

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



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.



Volunteer Interest


Loss History/Lessons


Your Expectations


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.



Optional-- 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.



If applicant is under age 18:

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

If my child wants to work in a direct patient support capacity, I give my permission for my child to submit to a TB test.

(per Hospice of Central Ohio’s Infection Control Plan protocols)




Optional

I grant full permission to the sponsors, organizers and affiliates to use my child’s 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- Agreement

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.


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.