Volunteer Application General InformationAre you 16 years of age or older?*YesNoName* First Last Work PhoneHome PhoneCell PhoneEmail* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employment / Work HistoryCurrent EmployerJob DescriptionEducationCurrently Attending School?YesNoDo you have future schooling plans?YesNoCollege Attended / School AttendingYear Graduated / Expected Graduation YearPersonal ReferencesReference #1Name First Last AddressPhoneReference #2Name First Last AddressPhoneReference #3Name First Last AddressPhoneEmergency ContactName First Last AddressPhoneDo you have a reliable means of transportation?YesNoDo you have Liability Insurance?YesNoVolunteer Availability(Select all that apply) Daytime Evenings Weekends Relevant BackgroundHave you had a personal experience with terminal illness or death within your immediate family in the past year?If yes, please explain.Have you experienced any deaths in your family or of those close to you?YesNoIf yes, specify your relationship to the person when they died.Please SpecifyHow did you hear about Hoffmann Hospice?Why do you want to volunteer for Hoffmann Hospice?Have you received hospice training previously? If yes, where and when?Are you a Veteran? If so, what branch of the military?Health StatusDescribe your healthGoodFairPoorIf poor, please explainHave you received a Tuberculosis (TB) screening within the past 90 days?YesNoDo you have any physical or medical restrictions, which might prevent you from performing certain activities?YesNoIf yes, please explainAreas of InterestSelect all that apply Hospice Home Patient/family caregiver relief Patient's Home Skilled Facility Bereavement support Interpreting Music Pet Therapy (Must have pet with certificate by PetPartners or Alliance) Limited transportation / run errands Fundraising / Health Fairs / Bulk Mailings / Special Projects Professional skills (legal, financial, pastoral, hair, nails, massage, interpreting, notary) Administrative Office/Clerical/Data Entry Buddy Brigade We Honor Veterans Community Service (Gardening, sewing, baking, event support) Interest: InterpretingPlease list any languages you write or speakInterest: MusicPlease Name InstrumentInterest: Professional SkillsPlease list any professional skillsInterest: Administrative SkillsPlease list any administrative skillsAre you able to make a six-month to one-year commitment to Hospice volunteering?YesNoPlease list any special hobbies, talents, or services you would be willing to share:In submitting my application as a prospective volunteer for Hoffmann Hospice, I authorize the agency to contact employers and references provided and to gather other information as appropriate to determine my suitability to serve in such a capacity. Name First Last SignatureDate* Date Format: MM slash DD slash YYYY Captcha This iframe contains the logic required to handle Ajax powered Gravity Forms.
