HOSPICE APPLICATION- full

Date of Application

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home Phone

Area CodePhone Number

Work Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

Off Cape Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date(not required)

MonthDayYear

Have you been convicted of a felony within the last 7 years? Answer no for 1st conviction of drunkenness, minor traffic violation, disturbance of peace, or simple assault.

Emergency Contact

First NameLast Name

Relationship

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

Work Phone

Area CodePhone Number

ext. number

Do you currently or have you previously worked for the VNA of Cape Cod, Inc.?

Highest Level Achieved

Major

Minor

Certificates Granted

Are you currently employed?

Employer

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Work Phone

Area CodePhone Number

ext. number

Are You Retired?

Describe any previous work experience

How will volunteering affect your work responsibilities?

Special Training And Hobbies

Prior volunteer experience

Languages, (other than English) you read, write, speak or translate

What are your reasons for volunteering?

Reasons for selecting the VNA

How were you referred?

What kind of volunteer work interests you? Check all that apply

Day Of Week

Time of Day

Months

Frequency

Location

Reference 1

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Reference 2

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Why are you considering becoming a hospice volunteer? Include what you expect to gain from the experience and what you might find most difficult.

Have you ever spent time with someone very sick or dying?

If yes, please explain.

Please describe a significant grief/loss experience you have had, e.g. a recent move, job loss, divorce or separation from family or close friend(s):

Would you like to share anything else about your interest in hospice volunteering?

In accepting a volunteer position at the Visiting Nurse Association, I understand that:

A patient or client’s name, clinical, records, other information about their health, social, financial circumstances, and about what takes place in the home shall be kept confidential and shall be released only as required by law or authorized by the patient or client.
My services are donated to the VNA without contemplation of future employment and given for humanitarian, religious or charitable reasons.
I may resign from the volunteer program after notice to my immediate supervisor and the volunteer coordinator.
I shall not sell or attempt to sell personal goods or services, request contributions or solicit persons to sign or distribute political petitions on VNA premises or in patient or client’s homes.
I shall be punctual and conscientious, conduct myself with dignity, courtesy and consideration of others, and endeavor to make my volunteer activities professional in quality.
I shall attempt to resolve any problems related to my volunteer activities with my supervisor, and, if unsuccessful, attempt to resolve such problems with the volunteer coordinator.
I shall at all times uphold the philosophy and relevant policies of the VNA.
I grant the VNA of Cape Cod, Inc. permission to take and use written material, videos and/or photos in which I am included, for publicity purposes. I acknowledge I will receive no compensation for any publicity that may arise from the use of any afore mentioned materials, If I do not wish to be photographed or interviewed, I understand it is my responsibility to notify the volunteer coordinator and/or the operators of any production equipment of my objection.
I understand the VNA reserves the right to dismiss any volunteer as a result of:
1. Failure to comply with confidentiality policies
2. Failure to comply with VNA policies, rules and regulations
3. Three or more absences without prior notification.
4. Unsatisfactory attitude, work, or appearance
5. Any other circumstances which, in the judgment of the VNA would make continued volunteer service contrary to the best interests of the VNA.

I have read each of the above conditions and I agree to be bound by them and that all information on this application is true and complete to the best of my knowledge.

Signature

Date

MonthDayYear

Demographic Information

Education

Employment

Interests

Availability

References

Hospice Volunteer

VOLUNTEER WORKERS AGREEMENT