Hospice Volunteer Application

Name*

First Last

Address*

Street Address City State ZIP

Phone*

Phone Type*

Email*

Occupation*

Which is the total number of hours per week that you are available?*

Weekday morning
Weekday afternoon
Weekday evening
Weekend morning
Weekend afternoon
Weekend evening

In which areas are you interested in volunteering?*

Patient visits (centers)
Patient visits (community)
Vigil visits (bedside, actively dying)
Office support
Bereavement
Other

Do you speak any languages other than English? If so, explain.*

Summarize any skills and qualifications you have acquired (through employment, previous volunteer work or other activities) as you see them pertaining to Hospice care.*

Why do you want to be a SALMON VNA and Hospice volunteer?*

What are your personal thoughts and feelings about death and dying?*

Have you ever been with someone at the time of their death?*

Yes
No

If yes, please explain.*

Have you ever provided care to someone who was dying?*

Yes
No

If yes, please explain.*

Have you had a significant loss in the past year?*

Yes
No

Reference 1 Name*

First Last

Reference 1 Phone*

Reference 1 Address*

Street Address City State ZIP

Reference 2 Name*

First Last

Reference 2 Phone*

Reference 2 Address*

Street Address City State ZIP

Reference 3 Name*

First Last

Reference 3 Phone*

Reference 3 Address*

Street Address City State ZIP

Phone

This field is for validation purposes and should be left unchanged.

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