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Volunteer
Volunteer Application
Volunteer Application
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
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Title
First
Middle
Last
Suffix
Address
*
Street Address
Address Line 2
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Armed Forces Americas
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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.
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.
*
Music
Pet Therapy
Aroma
Art
Massage
Hairdressing
Manicurist
Reiki
Relaxation
Healing Touch/Hands of Light
Other
Areas of Interest, Availability and Skills
Please select your areas of interest in providing Direct Patient Family Care.
*
Private, residential home
Nursing facility
Assisted living
Hinkle Hospice House
Errands
Meal delivery
Complimentary therapies
Companionship
Respite care
Light housekeeping
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.
*
Clerical support
Fundraising
Mailings
Marketing
Courier
Events
Crafts
Birthday cake provider
Data entry
Answering phones
Outreach and public speaking
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.
*
0-10 miles
10-20 miles
20-30 miles
30+ miles
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
*
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.