Hospice Volunteer application Form

Volunteer Application

Date:*

PERSONAL INFORMATION

Name*

First Name

Last Name

Phone:*

Cell Phone

E-mail:*

Current Address:*

Address Line 1

Address Line 2

City

State

ZIP Code

Social Security:

Birth Month/Year*

In Case of Emergency,Notify:*

Their Relationship:*

Telephone:*

EDUCATION

Are you currently attending school?

Yes No

If yes, where?

Education/ Special Training / Foreign Languages:

High School:

Technical School:

College:

Post Graduate:

VOLUNTEER EXPERIENCE

How did you hear about volunteering for Hospice El Paso?*

What made you decide to volunteer?*

Have you volunteered before? If yes, where and in what positions*

CURRENT EMPLOYMENT

Company Name

Telephone:

How Long:

Position:

Supervisor:

REFERENCES (DO NOT LIST RELATIVES PLEASE)

1. Reference Name*

Relationship:*

Address:*

Address Line 1

Address Line 2

City

State

ZIP Code

Telephone:*

2. Reference Name:*

Relationship:*

Address:*

Address Line 1

Address Line 2

City

State

ZIP Code

Telephone:*

3. Reference Name:*

Address:*

Address Line 1

Address Line 2

City

State

ZIP Code

Telephone:*

Relationship:*

Have you ever been arrested or convicted of a misdemeanor or felony?*

Yes No

If yes, please give date, location and disposition of your case:

Please check to acknowlege the following statement:*

A conviction record will not necessarily be a bar to selection as a volunteer. This information will be used only for volunteer related purposes and only to the extent permitted by applicable law.

Do you have any physical restrictions that may affect your placement t with Hospice El Paso. If yes, what is the limitation:*

Medical Reference: Doctor:

Telephone:*

When was your last Tuberculosis test:*

Have you had the Hepatitis B vaccine?*

Please check box to acknowledge the following statement:*

All Volunteer applicants are required to have a pre-acceptance physical and drug/alcohol screen.

Skills/Hobbies

Computer

Computer Copy Machine Other

Hobbies/Skills/Specials Interests:*

Are you a veteran?*

Yes No

Foreign Languages:*

Do you Drive?*

Yes No

Driver's License # and State:

Address Line 1

Address Line 2

City

State

ZIP Code

Please check box to acknowledge statement*

You will be required to provide Hospice el Paso with a copy of your driver's license and liability insurance. A driver's record check will be conducted upon acceptance.

What days and times are you available?

Acknowledgement and Consent...please check all boxes*

The above information is accurate and correct to the best of my knowledge. I understand that I am providing services strictly on a voluntary basis and that I have no expectation of compensation. I voluntarily waive, release and hold harmless Hospice El Paso, its elected and appointed officials, officers, employees, agents and other volunteers from any and all claims, causes of action and damages for bodily injury or death that I may suffer as a result of, or in any manner connected with, directly or indirectly, my participation as a volunteer when such bodily injury or death is the result of my own negligent or intentional acts or omissions or those of another volunteer. I understand that his waiver and release precludes my right to recovery of damages in the event I am injured in the course of performing my volunteer duties.

I shall defend, hold harmless an indemnify Hospice El Paso, its elected and appointed officials officers, employees, agents and other volunteers, from and against all damages, claims, liabilites, causes of action, judgements, settlements, costs and expenses (including, but not limited to reasonable expert witness and attorney fees) that may at any time arise or be claimed by any persona as a result of bodily injry, death or property damage, or as a result of any other claim or cause of action of any nature whatsoever, arising from or in any manner connected with, directly or indirectly, my negligent or intentional acts or omission in performing any and all volunteer duties.

Signature*

[clear]

Use your mouse or finger to draw your signature above

Your signature indicates your approval for us to check personal references, perfrom a criminal history background check, OIG exlusion data check, drivers record check, perform an employee misconduct registry check/nurses aide registry check and contact your physician to determine if you are able to perform the duties of the volunteer position you have applied for in a reasonable and safe manner. The organization is not obliged to provide palacement, or are you obligated to accept the volunteer position offered. Opportunity for volunteers are provided without regard to religion, creed, national origin, age, or sex.

Date:*