Catholic Hospice Volunteer Application
Date of Application:
Name:
Date of Birth:
Address1:
Address2:
City:
State:
Zip:
Email Address:
Cell Phone:
Home Phone:
Work Phone:
May we contact you at work?
Yes
No
Hours that you work:
Suitable Time: Daytime Evenings Weekends
Total number of hours per week you could be available for hospice volunteering:
How many days per week?
Which days would you be available?
 
Employment: Please list your employer(s) for the past five years
Employer1
Dates:
to
Name:
Occupation/Position:
 
Employer2
Dates:
to
Name:
Occupation/Position:
 
Employer3
Dates:
to
Name:
Occupation/Position:
   
Languages spoken other than English:
Language:        Fluency Level:
Language:        Fluency Level:
Language:        Fluency Level:
 
Personal Information
Do you have volunteer experience?  please specify:
How did you learn about Catholic Hospice? 
What inspires you to join the catholic hospice team?
 
Are you comfortable working with someone of a different religious faith than you?
Yes
No
 
Are you able to work with someone who practices a different lifestyle than you?
Yes
No
 
Are you willing to provide transportation for patient/family if needed?
Yes
No
 
Are there any special circumstances relating to your health that we should consider when assigning you to a patient?
Yes
No
If yes, please explain:
 
Have you experienced the loss of a loved one – friend or family?
If yes, when did this occur? 
How did this person’s death affect you?
 
Volunteer Opportunities
Please indicate your volunteer area of interest(s):
Patient Care
Bereavement Visitation
Bereavement Telephone Contact
Bereavement Mailings        
Clerical
Fund Raising
Public Relations
Professional Consultation (specify area of expertise):
Other, please specify:
 
References
Please list three personal references (no relatives) whom you have known for at least one year.
Reference1
Name:
Address1:
Address2:
Phone No:
 
Reference2
Name:
Address1:
Address2:
Phone No:
 
Reference3
Name:
Address1:
Address2:
Phone No:
 
Note:The information provided in the application process will assist us in determining appropriate volunteer assignments.   The Catholic Hospice team is committed to making your experience rewarding and beneficial to the community which we serve.  Thank you for your interest in volunteer opportunities with Catholic Hospice.