Volunteer Application

Please complete this application to become a registered volunteer with Hospice of Davidson County. One of our volunteer coordinators will reach out to you after your application is processed. Thank you for your desire to volunteer your time with us!

Name*

Title First Middle Last Suffix

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Enter Email Confirm Email

Do you have a valid NC driver's license?*

Yes
No

If yes, please list driver's license number.

Ethnicity

Emergency Contact Information

Name

First Last

Relationship

Phone

If you are under 18 years of age, please enter your parent/guardian name and number.

Name

First Last

Phone

Volunteer Experience

Please list previous volunteer experience (organization, location, dates, hours served, and what you did).

Please list organizations, churches or clubs in which you are active.

Have you ever been convicted of any unlawful offenses, other than minor traffic violations?

Yes
No

If yes, please explain in detail.

Education & Speciality Training

High School*

City, State

Did you graduate?

Yes
No

Community College, College or University*

City, State

Did you receive a degree or certificate?

Yes
No

If so, what type of degree did you receive?

Graduate/Professional College or University*

City, State

Did you receive a degree or certificate?

Yes
No

If so, what type of degree did you receive?

Are you attending school now?

Yes
No

Expected Graduation Date

Course of Study

Special Services & Complimentary Therapies

Please check all services or therapies in which you have experience.*

Areas of Interest, Availability and Skills

Please select your areas of interest in providing Direct Patient Family Care.*

Please select all you are interested in with Grief Support and Bereavement.*

Making phone calls
Home visits
Support groups
Transportation
Administrative support

Please select areas of interest in Non-Direct Patient Services.*

Weekdays mornings
Weekday afternoons
Evenings
Weekends

Are you available on short notice?

Yes
No

Are you willing to commit to volunteering at Hospice of Davidson County for a minimum of one year?*

Yes
No

Do you have access to transportation?*

Yes
No

Do you currently have an immediate family member receiving hospice care?*

Yes
No

Have you experienced the loss of a loved one during the past year?*

Yes
No

If yes, what was your relationship to the deceased?

Do you have any allergies that would prevent you from providing in home care?*

Yes
No

If yes, please list allergies.

Number of miles willing to travel from your home to provide volunteer support, keeping in mind the agency provides mileage reimbursement.*

Military Service

Are you or were you a member of the U.S. Military? Please select your status here.*

Active Duty
Reserve
Retired
Discharged
No Status

What was your branch of military service?*

Army
Navy
Air Force
Marines
Coast Guard
National Guard

Are you interested in serving as a volunteer in our Vet-to-Vet program?*

Yes
No

Employment Information

Are you retired?*

Yes
No

Are you currently employed?*

Yes
No

Current employer

Position

Phone

May we contact you at work?

Yes
No

Please describe your work experience.

Character & Professional References

Please provide 2 references.

Name	Phone	Email

Code of Ethics for Volunteers

As a volunteer, I realize that I am subject to a code of ethics similar to that which binds the professionals in the field in which I work. I, like them, assume certain responsibilities and expect to account for what I do in terms of what is expected of me. I understand that any information that is disclosed to me while assisting the Hospice is confidential. I interpret "volunteer" to mean that I have agreed to work without financial compensation. As a volunteer worker, I expect to do my work according to the standards set forth in Volunteer Policies and Procedures. I understand that my acceptance as a volunteer is contingent upon the successful completion of my references, criminal background/sex offender investigation and pre-volunteer drug screen. I understand volunteers must attend a volunteer workshop requiring 12 hours of education and that Accreditation Commission for Healthcare (ACHC) requires 12 hours of continuing education annually. I understand that I must also submit to a TB test prior to volunteering.

Full Legal Name*

Signature using full legal name

Date*

Declaration

I hereby certify that the statements made on this application are true and correct to the best of my knowledge. I understand that by submitting this application, I authorize inquiries to be made concerning my character and public records for the purpose of determining my suitability as a volunteer.

Full Legal Name*

Signature using full legal name

Date*

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Comments

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