Personal Data

Name   Date of Birth: m d y

Address: City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip

Home Phone: Cell Phone:
                       
Email:

Employer: Occupation

Work Phone:    Can you receive calls at work? yes no

In Case of Emergency contact:   Phone:

Address:

City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip

Professional License or certification (please specify):
Date of Expiration m d y

Date of Expiration m d y

Education/special training:


Work Experience:


Community Involvement/Volunteer work (current and previous):

Hobbies, personal interests, activities:

Do you have any special needs that would limit your volunteer experiences? Yes No
If yes, please explain:

Volunteer Information:

Why do you want to be a Hospice Volunteer?

How did you hear about the Judith Karman Hospice volunteer program?



Does your family/spouse support your decision to be a hospice volunteer? 



Has someone close to you died within the past year?  Yes No
If yes, please explain:


Identify areas of interest for volunteering: (non-patient does not require 20 hour education course)

Check your availability for volunteer service:

Weekdays    Weekends    Evenings    Mornings    Afternoons

Other:

Do you speak a language other than English?

Language     speak  read  write

Language     speak  read  write     

Other special services: (manicurist, hairdresser, masseuse, etc.)

Do you have access to transportation?           Yes              No

What qualities (skills, talents, knowledge, and experiences) do you feel you can incorporate into your volunteer position?

How do you see hospice volunteer work satisfying your personal needs or reasons for pursuing a volunteer position?

PATIENT CARE VOLUNTEER INFORMATION:

Would you be willing to work with an AIDS or HIV+ patient?   Yes   No

Would you be willing to work in a home where the patient and/or family smoke?   Yes  No

Do you smoke?  Yes   No

Are you willing to work with a patient / family that have a history of alcoholism? Yes No

How many miles are you willing to drive? (Round trip mileage) 

DEATH AND DYING

Do you fear death?

Do you fear the death of a loved one more or less than your own?             More      Less

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

Have you ever provided “nursing” care to anyone?  If yes, please explain.   yes  No

How do you feel about your own death?
I do not think about my own death    sorrowful    natural    frightening
painful   lonely    joyful    heavy     peaceful      dark

Other

Comments

Two Personal References (excluding family members)
Please provide a complete address, as references are verified by mail.

Refrence #1.

Name Relationship

Address 

City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip  

Home phone     Work phone 

Reference #2.

Name    Relationship 

Address 

City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip                      

Home phone     Work phone 

AGREEMENT:

I understand that I will be offered and be required to complete Hospice Volunteer Training.

I agree to fulfill all requirements related to my role as a volunteer with Judith Karman Hospice.

Yes No

CODE OF ETHICS FOR VOLUNTEERS

 As a volunteer, I realize that I am subject to a code of ethics similar to that which binds the professional in the field in which I work.  I, like them, assume certain responsibilities and expect to account for what I do in terms of what is expected of me.  I understand that any information that is disclosed to me while assisting Judith Karman Hospice is confidential and that this confidentiality is protected by the polices of Judith Karman Hospice.

I interpret “volunteer” to mean that I have agreed to work without compensation in money.  Having been accepted as a volunteer worker, I expect to do my work according to the standards set forth in the Volunteer Policies and Procedures.

I promise to take to my work an attitude of open-mindedness; and, I am willing to continue my education in the field through in-services offered to volunteers.  I believe that I have an obligation to my work, to those who direct it, to my colleagues, to the community and to those for whom it is done.

I accept this Code for the volunteer as my Code, to be followed with care and compassion.

Declaration:

I hereby certify that the statements made on this application are true and correct to the best of my knowledge.  I understand that, by submitting this application I authorize inquiries to be made concerning my employment, character, and public records for the purpose of determining my suitability as a volunteer.  I affirm that I have read the volunteer Code of Ethics and agree to abide by its regulations.  I agree to respect the confidentiality of any client information I acquire in the course of my volunteer activities with Judith Karman Hospice.  I understand this information will be held in the strictest confidence.
               
I accept