Apply to Volunteer Please enable JavaScript in your browser to complete this form.Name *FirstLastBirth DateAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Home Phone *Cell Phone *Work Phone *Emergency Contact Name and TelephoneOccupationPlease list your present employer and a previous employer. If you are not employed currently please write unemployed. If you are retired please write retired. Present Employer (if applicable)Position Held and Date(s) of EmploymentPrevious Employer (if applicable)Position Held and Date(s) of EmploymentEducationFor the following, please list Name, City/State, Years Attended, & specify a Degree if applicable. High SchoolUndergraduateGraduate/ProfessionalPlease list any related skills or qualificationsVolunteer ScreeningHave you been convicted of a felony?YesNoDo you have any criminal charges pending against you or were you ever convicted of (or plead no contest or nolo contendere to) any crime or offenses including: felony, misdemeanor, municipal ordinance violation or tribal court conviction? If yes, please list each and attach an explanation.YesNoExplanation:Have you experienced a loss of a loved one within the last year?YesNoAbout YourselfWhy do you want to become a Volunteer with Savior Hospice?How did you find out about the Savior Hospice Volunteer program?Please list any experience that would enrich your volunteer activities (e.g. caring for a relative, hospice situation, etc.):Please check any area(s) you wish to serve as a VolunteerPatient SupportOffice WorkClergyPublic SpeakingSpecial Events/HolidaysBereavement SupportHomemakingGardeningErrandsFamily SupportNursing HomeInpatient SettingReferencesReference #1 Name & TitleReference #1 PhoneReference #2 Name & TitleReference #2 PhoneI certify that all the information submitted by me on this application is true and complete to the best of my knowledge. I authorize Savior Hospice to act as my agent in obtaining information from any person or company concerning myself, without liability to such person or company, or to Savior Hospice. I understand that if, in the judgment of Savior Hospice, any information has been misrepresented, falsified or omitted, any offer of a volunteer position may be withdrawn or any volunteer position terminated without obligation or liability on the part of Savior Hospice. I understand that I am required to abide by all rules, policies, and procedures of Savior Hospice. I understand that I will receive no financial compensation and that full participation in the hospice volunteer training program and additional training, as determined by the volunteer coordinator and/or designee, is a prerequisite to a volunteer assignment with a hospice patent. *I agreeEmailSubmit
