Alternative Hospice - Volunteer Application

Volunteer Application

Fields marked with a red dot ( ) are required.

Required Information

First Name:
Last Name:
Email:

Personal Information

Street Address:
Address (2nd):
City:
State:
Zip Code: [5 digits]
Birth Date (for birthday card list only):
Home Phone: (xxx) xxx-xxxx
Cell Phone: (xxx) xxx-xxxx
Work Phone: (xxx) xxx-xxxx
Occupation (if retired, please list previous occupations):
Driver's License #:
State:
Vehicle Ins. Carrier:
Emergency Contact:
Relationship:
Phone: (xxx) xxx-xxxx
Why have you chosen to volunteer with Alternative Hospice?
What personal characteristics will enable you to work with hospice patients?
Please describe any work or other experiences which you feel has prepared you to ba a volunteer:
How many year(s) ago was your last impactful death:
Relationship to Most Recent Deceased:
Fluent Languages (other than English):
Have you been convicted of a felony, or been notified of any exclusion actions?
Indicate specialty skills you are willing to provide as a volunteer. Current Certification or professional license required. Hairstyling
Massage
Reiki
Healing Touch
Pet Therapy
License Type:
License #:
Expiration Date:
How did you hear about volunteering with Alternative Hospice?

References: I understand that I will be required to provide two reference forms to individuals who know me on a personal or professional basis. By submitting this online form, I am authorizing Alternative Hospice to contact my references regarding my appropriateness as a volunteer.

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