Volunteer Application

Dear Prospective Volunteer:

Thank you for your interest in volunteering with Hope Hospice. Each volunteer is an essential part of caregiving and a valued member of our team.

Volunteer classes will give you the tools needed to feel comfortable volunteering in any office or clinical setting in our organization. Classes are offered throughout the year at various locations in our service area.

For your convenience, the Volunteer Application is available below, or you may call (239) 433-8069 or (800) 835-1673 to receive an application by mail. We will contact you upon receipt and review of your application to schedule an initial interview, either on the phone or in person.

If you’re looking for a rewarding and challenging experience, you’ll find it as a Hope Hospice volunteer! Should you have any questions, please do not hesitate to call us at (800) 835-1673.

*Name:
	Male Female
*Address:
*City:
*State:
*Zip:
*Date of Birth
Social Security Number:	For background check
Home Phone:
Cell Phone:
*Email
Have you applied for a staff position at Hope within the past 30 days?	Yes No
Employer:
Work Phone:
May we call you at work?	Yes No

How did you hear about Hope's Volunteer Program?	Word of mouth Newspaper Web site Family Member Bereavement Group Speaker/Presentation Other

Are you a seasonal resident?	Yes No

What months are you available to volunteer?	Jan Feb March April May June July Aug Sept Oct Nov Dec

Alternate address:

PLEASE NOTE: We hold Volunteer Applications for 90 days


Preference for Volunteer Orientation Sessions:	Days Saturday


Preferred Orientation Location	Fort Myers Cape Coral Bonita Springs Lehigh Acres Sebring Lake Placid Lakeland Winter Haven LaBelle Clewiston Wauchula Buckhead Ridge


PLEASE NOTE: Class times and locations vary throughout the year


*Have you ever been convicted of a crime, including DUI or DWI?	Yes No


VOLUNTEER INTERESTS: Please indicate areas of interest:


	Hope Hospice - patient & family support, visits, phonecalls, transportation Hope Connections - congregate meal sites; home care Glades/Hendry Counties Hope Health Center- activities, entertainment, meal assistance, socialization Lee County Hope Life Care (Long Term Care) - home visits, patient/family support, errands, socialization Hope Chest - North Fort Myers Resale Shop Office Assistance Other


	Prior to attending Volunteer Classes, all Volunteers are required to have a completed application (with references); a criminal background check; interview; and to have completed step one (1) of a two (2) step TB testing process.

	I understand that I will be asked to complete a confidential medical questionnaire during volunteer orientation.
	Based on my answers, I may be asked questions concerning my ability to perform volunteer related functions.
	I also understand that I will be screened for Tuberculosis using a two (2) step PPD Intra-dermal Skin Testing and/or by submitting a negative chest x-ray.
	I understand that if I have a positive skin reaction to the TB test, I cannot volunteer or attend training until a negative chest x-ray is submitted to Hope. By entering my name below, I understand and agree to these terms.


*Type Name/Date:



Please answer these questions to the best of your ability:


Has anyone close to you died?	Parent Sibling Spouse Child Friend In-law Grandparent Relative


When did this death occur?	Less than one year Within last five years Within last 10 years Over 10 years


Was this death the result of a terminal illness?	Yes No



If a patient should have a lifestyle that is different to your own beliefs and values, what is your reaction?	Say nothing Accept and respect Try to change them Ask to be excused



	How did the following reasons influence your decision to volunteer for Hope Hospice? Extremely - 1; Very much - 2; Moderately - 3; Slightly - 4; Not at all - 5

Community service	1 2 3 4 5
Make new friends	1 2 3 4 5
Help others	1 2 3 4 5
Increase problem solving / coping skills	1 2 3 4 5
Learn to face death	1 2 3 4 5
Spiritual growth	1 2 3 4 5


	To what extent do you feel you are a good listener?
	Extremely Very much Moderately Slightly Not at all


	How do you rate your communication skills?
	Excellent Very Good Average Below average Poor



Please Read and Sign


	I give permission to Hope HealthCare Services, to use the information in this questionnaire. All information will remain confidential.
	Please read the following statements carefully; they constitute the conditions under which you may volunteer for Hope HealthCare Services.
	Hope HealthCare Services advises you that as your volunteer application is being processed, an investigative report will be ordered and references will be contacted.
	Upon your written request within a reasonable time from the date of this application, additional information as to the nature and scope of the report will be provided.
	The purpose is, among other things, to verify the completeness and accuracy of the volunteer application.
	I authorize the persons, schools, employer, and other organizations named in this application to provide Hope HealthCare Services with all information that may be required to arrive at a volunteer placement decision.
	I hereby release and indemnify Hope HealthCare Services, each of my references, and any other sources of information, and agree to hold them harmless from any claims arising from this authorization.
	The information that I have provided on this volunteer application is accurate to the best of my knowledge and subject to validation by Hope HealthCare Services.
	I understand and agree that any misrepresentation or omission of a fact in my application may be justification for refusal of being accepted as a volunteer. By entering my name below, I understand and agree to these terms.


*Type Name/Date:



Volunteer Reference Checklist




	By typing my name below, I give permission to Hope HealthCare Services to contact the references listed.

*Type Name:



	Personal or professional references are requested. Please do not include family as a reference. Please provide reference name, address and phone only.


Reference #1

*Name of Volunteer Applicant:

*Reference Name:
Address:
City:
State:
Zip:
*Phone:

Email address:


Reference #2


*Reference Name:
Address:
City:
State:
Zip:
*Phone:
Email address:

Volunteer Application

PLEASE NOTE: We hold Volunteer Applications for 90 days

PLEASE NOTE: Class times and locations vary throughout the year

VOLUNTEER INTERESTS: Please indicate areas of interest:

Please answer these questions to the best of your ability:

Please Read and Sign

Volunteer Reference Checklist

Reference #1

Reference #2