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James Kirchoffer, MD

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Michelle Helms, MD

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VNA & Hospice Volunteer Application Form

Thank you for your interest in volunteering for Cooley Dickinson VNA & Hopsice. Please fill out the form below to submit your volunteer application to VNA Hospice Volunter Coordinator Carol Devine.

Direct Patient Service Volunteers must be at least 18 years old. All other volunteers must be at least 14 years old.
Hospice does not discriminate on the basis of race, color, national origin, religion, disability, sexual orientation, gender identity, or age in admission or access to treatment or participation in its programs or activities.

Mr.Mrs.MissMs.

First Name

Middle Name

Last Name

Street Adress

City

State

Zip

Home Phone

Business/Cell Phone

Email address

Confirm email address

Can you be contacted at work?
YesNo

Occupation

Work Hours/Days

When are you generally available to volunteer?
DaytimeEveneingsWeekends

Does your availability change? (i.e. in summer, in bad weather, according to changing work schedule)
YesNo

Please Explain

Please list any hobbies or special interests.

Do you speak a language other than English?
YesNo

If yes, which language(s) do you speak?

Do you have personal transportation?
YesNo

In which volunteer experiences are you interested and/or willing to do?
Regular one-to-one volunteerPatient transportationSpecial projects/errandsOffice workFundraisingJourney Home (bedside) singers

Other

EDUCATIONAL BACKGROUND

School 1:

Major:

Degree(s)

Dates Attended
From

To

School 2:

Major:

Degree(s)

Dates Attended
From

To

School 3:

Major:

Degree(s)

Dates Attended
From

To

WORK EXPERIENCE

1 | Employer Name

Job Title

Dates Employed
From

To

2 | Employer Name

Job Title

Dates Employed
From

To

3 | Employer Name

Job Title

Dates Employed
From

To

VOLUNTEER EXPERIENCE

1 | Volunteer Position

From

To

2 | Volunteer Position

From

To

3 | Volunteer Position

From

To

REFERENCES

Please give the name, address and phone number of two individuals whom we might contact for letters of recommendation:

1 | Name

Address

Phone

2 | Name

Address

Phone

I give permission for Cooley Dickinson Health Care to contact the references listed above (check box to agree)

Please respond to the following questions

Why do you want to be a Hospice volunteer?

What do you feel you would bring to the program?

What personal experiences have you had with serious illness, loss (may include divorce, job loss, etc.) and death? How did you react in these situations?

Do you have experience in assisting others in the process of dying, death or grief?

Please Read Carefully

By clicking "I accept," I attest that all of the above statements are true to the best of my knowledge. I understand that any misstatements are sufficient cause for my dismissal. I authorize the Cooley Dickinson Health Care Corporation to verify any information presented in this form and to request statements from references. In the event of my volunteering for the Cooley Dickinson Health Care Corporation, I agree to comply with all of the Cooley Dickinson Health Care Corporation’s rules and regulations as they may be changed from time to time.

I ACCEPT

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