VOLUNTEER APPLICATION

Please check the position you are interested in: Hospice Office Special Events/Fundraising Community Outreach Bereavement Other     First Name Last Name Street Address Suite/Apt# City State Zip County E-mail Home Telephone Cell/Other Date of Birth Social Security - - In case of emergency please notify Relationship Telephone Address City State Zip Current Employment Information Employer Address City State Zip Business Telephone Position Hours Worked May we call your employer? YES NO Education Highest Grade Level Attended Where Degrees/Certificates obtained Availability - State days and times Do you have (please check all that apply) Own reliable transportation Auto Insurance Valid Drivers License Special Skills and/or Interests, Hobbies (please list) Health Questionnaire Have you had any serious illness in the past years? If so, please describe.   Do you have any physical limitations that would be a hindrance to your volunteer role? If so, please describe   Getting to know you Why do you want to volunteer with Heritage Hospice, Inc.?   What do you feel is the volunteer's role in hospice and what is the importance?   How did you hear about Heritage Hospice, Inc.? (Please be specific)   As part of our volunteering criteria, you will need a tuberculosis test. Would this be OK with you?   YES NO   I hereby certify that the above information is true and correct to the best of my knowledge. I realize this information is confidential and may be used to determine my eligibility to volunteer. I authorize Heritage Hospice, Inc. to perform any inquiries regarding these facts.   I also agree to submit to any examinations which may include chest x-ray, appropriate laboratory tests, and/or immunizations that may be necessary as part of my volunteer service. I authorize my physician to furnish information regarding my current health. Signature  (Type your full name to certify above statements) Date: (mm/dd/yyyy)