VNA & Hospice Volunteer Application Form

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:

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.