Online Volunteer Application Name(Required) First Last Home Phone(Required)Work PhoneAddress(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Birthdate MM slash DD slash YYYY In Case of EmergencyNotify(Required) First Last Relationship(Required) Phone Number(Required)AvailabilityCheck All That Apply(Required) Days Evenings Weekends Check All That Apply(Required) To work with patients and families To do office work To work on fundraisers To work with families in bereavement To answer phones To work on Events Committees Volunteer ExperienceWhy did you decide to volunteer for hospice?(Required)Please describe current or past volunteer experiences:(Required)Experiences with Death & DyingHave you experienced the deaths of family members or others close to you? If yes, please explain and give dates of deaths.(Required)Have you had a hospice experience? If yes, please explain.(Required)Special Skills (Check All That Apply)(Required) Nursing Music Art Computer Teaching Cooking Reiki or Therapeutic Touch Animal Care Other Please Specify(Required) Do you speak a language or languages other than English(Required) Yes No Please Specify(Required) Employment InformationAre you currently employed? Yes F/T Yes P/T No Employer Name and AddressCurrent Position Are you currently in school?(Required) Yes No Military ExperienceAre you a veteran?(Required) Yes No MiscellaneousDo you drive?(Required) Yes No Do you have a car available to you?(Required) Yes No Do you smoke?(Required) Yes No How did you hear about UHR?(Required) Are you a member of the Retired Senior Volunteer Program (RSVP)?(Required) Yes No Do you have any physical restrictions that might affect your volunteer placement such as bad back, hearing or vision problems, asthma, allergies, atc.? If yes, please describe.Have you ever been convicted of a crime? Yes No The information I have provided on this application is true and complete to the best of my knowledge. Any misrepresentation or omission of any fact in my application, resume, or any other materials, or during interviews, can be justification for refusal of employment, or, if employed, termination from Hospice’s employment.Name(Required) First Last Date MM slash DD slash YYYY
