VOLUNTEER APPLICATION
|
| Name: |
|
| Social Security Number: |
|
| Today's Date: |
|
| Address: |
|
| City: |
|
| State: |
|
| Zip: |
|
| Telephone: |
Home:
Work: |
| Email: |
|
| Do you have a valid GA Drivers License? |
|
| Employer: |
|
| Occupation: |
|
| Can you receive calls at work? |
Yes No |
| List 3 personal references (excluding relatives). Please include a complete address, phone number and relationship. |
| Reference 1 |
| Name: |
|
| Address: |
|
| Phone Number: |
|
| Relationship: |
|
| Reference 2 |
| Name: |
|
| Address: |
|
| Phone Number: |
|
| Relationship: |
|
| Reference 3 |
| Name: |
|
| Address: |
|
| Phone Number: |
|
| Relationship: |
|
| Emergency Contact |
| Name: |
Relationship: |
| Address: |
Telephone: |
| Education: |
| Highest level of education: |
High School College Graduate School
Other |
| Specialized Training or Skills: |
|
| Please list any licenses or certifications you have obtained (Include license number if applicable): |
|
| Please list any professional or community organizations that you are a member or organizations that you volunteer your time with: |
|
| Areas of Interest: |
|
| Do you know a language other than English? |
Yes No |
| Language: |
Speak Read Write |
| Language: |
Speak Read Write |
| How did you hear about Hospice Savannah? |
|
| Why do you want to volunteer here? |
|
| Days/Hours Available to Volunteer |
|
| List any talents or skills you posess that you would be willing to share with Hospice Savannah: |
|
| Death and Dying |
| Have you ever been with someone at the time of their death? |
Yes No |
| If yes, please briefly describe: |
|
| Have you ever provided care to anyone who was dying? |
Yes No |
| If yes, please explain: |
|
| |
CODE OF ETHICS
As a volunteer, I realize that I am subject to a code of ethics similar to that which binds professionals in the field in which I work. I, like them, assume certain responsibilities and expect to account for what I do in terms of what is expected of me.
I understand that any information that is disclosed to me while assisting Hospice Savannah, Inc. is confidential.
DECLARATION
I hereby certify that the statements made on this application are true and correct to the best of my knowledge. I understand that, by submitting this application I authorize inquiries to be made concerning my employment, character, and public records for the purpose of determining my suitability as a volunteer. I affirm that I have read the Volunteer Code of Ethics and agree to abide by its regulations. I agree to respect the confidentiality of any patient information I acquire in the course of my volunteer activites with Hospice Savannah |
| Please check this box if you agree to the above terms and conditions. (required) |
|
