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Shalom Hospice Volunteer Application
Last Name *
First Name *
Street Address *
City *
State *
Zip Code *
Email *
Best Contact Number *
Employment History/School History *
Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency? *
Conviction will not necessarily disqualify an applicant from employment.
If yes, describe in full.
Are the hours you seeking as a volunteer needed to satisfy a “community service” requirement associated with a disciplinary action? *
(Answering yes to the above does not constitute a bar to participate. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and the type of volunteer assignment will be taken into account.)
Highest Level of Education completed *
Emergency Contact name, address, phone number *
Ex: Jon Doe, 55 Cherry Street Money, GA 39806, 123-456-7890
Volunteer Ability *
Days Available *
Check all that apply
Time of Availability *
Have you experienced the loss of a loved one in the past few months?
Clear selection
If yes, what was the relationship?
Do you know a foreign language? *
If yes, what language and what is your proficiency?
Ex: Spanish, intermediate
Do you have any sign language skills?
Clear selection
Are you active in any other organizations?
Clear selection
Do you have any special skills?
Ex: arts, crafts, cooking, baking, sewing, etc.
Have you served in the military?
Clear selection
Do you have a car with valid insurance? *
Can you provide transportation to another volunteer? *
Have you ever been a caregiver for someone who died? *
Assignment Preference *
Areas of Interest *
Check all that interest you
Please tell us why you wish to become a hospice volunteer *
Please tell us what you feel hospice does for patients and families and how you feel about death/dying. *
I certify that the information provided in this application are true and complete to the best of my knowledge and understand, that, if accepted for a volunteer position, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL. I Authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency. I consent and agree that my use of a key pad, mouse or other device to select an item, button, icon or similar act/action while using any electronic service we offer; or in accessing or making any transactions regarding any document, agreement, acknowledgement, consent, term, disclosure, or condition constitutes your signature, acceptance and agreement as if actually signed by me in writing. Further, I agree that no certification authority or other third party verification is necessary to validate my electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of my signature or resulting contract between me and Shalom Hospice. I understand and agree that my eSignature executed in conjunction with the electronic submission of my application will be legally binding and such transaction will be considered authorized by Shalom Hospice. *
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