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Volunteer Application
Michael Hunt
2018-02-19T18:22:55+00:00
Savior Hospice Volunteer Application
Name
*
First
Last
Email
*
Phone
*
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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New Hampshire
New Jersey
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New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Emergency Contact Name and Telephone
Occupation
Please 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 Employment
Previous Employer (if applicable)
Position Held and Date(s) of Employment
Education
For the following, please list Name, City/State, Years Attended, & specify a Degree if applicable.
High School
Undergraduate
Graduate/Professional
Please list any related skills or qualifications
Volunteer Screening
Have you been convicted of a felony?
Yes
No
Do 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.
Yes
No
Explanation:
Have you experienced a loss of a loved one within the last year?
Yes
No
About Yourself
Why 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 Volunteer
Patient Support
Office Work
Clergy
Public Speaking
Special Events/Holidays
Bereavement Support
Homemaking
Gardening
Errands
Family Support
Nursing Home
Inpatient Setting
References
Reference #1 Name & Title
Reference #1 Phone
Reference #2 Name & Title
Reference #2 Phone
I 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 agree
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