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Cooley Dickinson Hospital Volunteer Application Form

VNA & Hospice Volunteer Application Form

Thank you for your interest in volunteering for Cooley Dickinson VNA & Hospice. Please fill out the form below to submit your volunteer application to VNA Hospice Volunteer Coordinator Tina Leflar. Please send a resume and/or a summary of your education and work history to cleflar@cooleydickinson.org, or use this form’s provided space where indicated.

Direct Patient Service Volunteers must be at least 18 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

    Last Name

    Street Address

    City

    State

    Zip

    Cell Phone

    Home or Business Phone

    Email address

    Confirm email address

    Can you be contacted at work?
    YesNo

    Occupation

    Work Hours/Days

    When are you generally available to volunteer?
    DaytimeEveningsWeekends

    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 a vehicle you can use to visit patients?
    YesNo

    In which volunteer experiences are you interested and/or willing to do? (Check all that apply)
    Regular one-to-one volunteerOffice workSpecial projects/errandsFundraisingJourney Home (bedside) singersMassageReikiMusic TherapyPet TherapyOther Complementary Therapy

    Other

    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?

    EDUCATIONAL BACKGROUND

    Tell us about your educational background. Include college(s), major(s), other areas of study, or email a resume to VNA Hospice Volunteer Coordinator Tina Leflar at the address above.

    WORK EXPERIENCE

    Tell us about your work experience/career (where you’ve worked, what you did, how long, etc. Or just email a resume to VNA Hospice Volunteer Coordinator Tina Leflar at the address above.

    VOLUNTEER EXPERIENCE

    Tell us about any previous volunteer experience.

    REFERENCES

    Please give the name, address, phone number and email of two individuals whom we might contact for letters of recommendation. You can also email this information separately now or after an initial interview to VNA Hospice Volunteer Coordinator Tina Leflar at the address above.

    1 | Name

    Address

    Phone

    Email

    2 | Name

    Address

    Phone

    Email

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

    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

    Today's Date:

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