Volunteer Application

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

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?

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.

Explanation:

Have you experienced a loss of a loved one within the last year?

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

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Savior Hospice, any information has been misrepresented, falsified or omitted, any offer of a volunteer position may be withdrawn or any volunteer position terminated without obligation or liability on the part of Savior Hospice.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

Savior Hospice Volunteer Application

Occupation

Education

Volunteer Screening

About Yourself

References