Hospice Of Gladwin  Area, Inc.

VOLUNTEER APPLICATION – Please print or type                                          
 
SECTION I


FULL NAME _____________________________________________________________________________________________


Home Telephone (     ) ____________________________   Work or Cell Phone  (     ) ________________________________

STREET & MAILING ADDRESS _____________________________________________________________________________

CITY ________________________________________________________ STATE _____________________ ZIP ____________

EMAIL ADDRESS ______________________________________  BIRTHDAY ________/_____/_______ SEX M ____ F ____

CURRENT EMPLOYER ___________________________________________________________________

                RELIGIOUS PREFERENCE* ________________________________________________________

DRIVERS LICENSE NUMBER _____________________________________ 

Have you ever been convicted of charges stemming from:             (Please state yes or no.)

Euthanasia (mercy killing)? _____________ Use/possession of an illegal drug or alcohol? _________  Theft?   __________  


EMERGENCY CONTACT _____________________________________________________________________________________

RELATIIONSHIP TO YOU _________________________________ TELEPHONE NUMBER _____________________________

FOREIGN LANGUAGE ________________________________________           UNDERSTAND______ READ _____ SPEAK ____

SECTION II – EDUCATIONAL DATA  (Indicate highest level attained)


HIGH SCHOOL  1 ___ 2 ___3 ___ 4 ___                 COLLEGE 1 ___ 2 ___ 3 ___ 4 ___                      DEGREE TYPE _____________

GRADUATE STUDIES ____________________________________________________                    DEGREE TYPE _____________

PROFESSIONAL TRAINING ____________________________________________________________________________________

SEMINARS/TRAINING IN DEATH EDUCATION  __________________________________________________________________

OTHER TRAINING ____________________________________________________________________________________________

SECTION III – EXPERIENCE WITH LIFE THREATENIING ILLNESSES


Have you any chronic health problems or disabilities?      Yes ________ No ________ If yes, please explain _______________


______________________________________________________________________________________________________________

Have you ever been seriously ill? ______ if yes, what was the cause of the illness? ____________________________________

Has any family member/close friend had a serious illness?  ______ Did it result in death? _____________________________

If yes, who and how recently? __________________________________________________________________________________

Please comment on that experience ____________________________________________________________________________


______________________________________________________________________________________________________________

SECTION IV – REFERENCES

Name __________________________________________ Address _____________________________________________________ 

City, State, Zip ___________________________________ Phone ______________________________________________________ 

Name __________________________________________ Address _____________________________________________________ 

City, State, Zip ___________________________________ Phone ______________________________________________________ 

Name __________________________________________ Address _____________________________________________________ 

City, State, Zip ___________________________________ Phone _______________________________________________________

SECTION V – RATIONALE


In order to better acquaint us with yourself, please indicate your reasons for wanting to serve as a Hospice Volunteer.   
 

 

Are you willing and able to participate in the Hospice Training Program (Approx. 20 hours?)?
 

I, THE UNDERSIGNED, ATTEST THAT THE INFORMATION ON THIS APPLICATION IS TRUE.  I GRANT MY CONSENT FOR HOSPICE OF

GLADWIN AREA TO CONTACT THOSE PERSONS LISTED AS PERSONAL REFERENCES AND CONDUCT A BACKGROUND CHECK.

 

Applicant’s signature __________________________________________________________  Date __________________________________ 

Please return this application as soon as possible to :                 Executive Director
                                                                                                                Hospice of Gladwin Area, Inc.
                                                                                                                PO Box 557
                                                                                                                Gladwin, MI 48624