Volunteer Application

Note: All items marked with an asterisk (*) are required.

*Today's Date:

*First Name:

*Last Name:

*Address:

*City: *State: *Zip:

*Date of Birth:

*Home phone:

Cell phone:

Work phone:

*E-mail:

Home/work fax:

*How do you prefer to be contacted?

Occupation:

Employer:

Education or Training (select highest level completed):

Professional Licenses and Certification

Type:

State (If applicable):

Certification Date:

Exp. Date:

Number:

Provide two references (excluding family members) whom we may contact. Please provide complete information:

Reference 1

*Name:

*Phone:

*Address:

*City: *State: *Zip:

Reference 2

*Name:

*Phone:

*Address:

*City: *State: *Zip:

*Have you had any criminal convictions in the last seven (7) years?

Note: Convictions will not necessarily bar an applicant from being considered for volunteering.

If yes, please explain:

Person to be notified in case of an emergency:

*Name:

*Relationship to you:

*Home Phone:

*Work Phone:

*Alternate Phone:

*Volunteer Experience (clubs/organizations/church):

Areas of Interest (hold down the CTRL key to select multiple items):

Patient/Family Care:

Administrative/Clerical:

Bereavement:

Special Projects:

Professional Services:

Other skills and interests (please list):

I am available to volunteer (hold down the CTRL key to select multiple items):

Days:

Time of day:

Hospice volunteers are required to participate in a training and/or orientation program. Are you willing and able to attend?

Hospice volunteers are required to keep records of their volunteer time and documentation of their activities which is a requirement by Medicare. We will provide forms and instructions. Are you agreeable to this requirement?

How did you hear about our hospice program?

Please describe any work or other experience which has prepared you to be a hospice volunteer:

Briefly explain any significant losses you have experienced that influence your views of death and dying, include when these losses occurred and your relationship to the deceased.

Please read the following and check the box below if you accept these terms:

I certify that all answers and information that I have included in this application are true, accurate and complete and that I have not knowingly withheld any facts, circumstances or other information which would, if disclosed, affect my application and opportunity to become a volunteer. I further understand that any false or misleading statement or omission of requested information will result in my application being rejected.

I acknowledge that Affinity Healthcare Services, Inc. (hereinafter the “Company”) will disclose to me via a separate notice that an Investigative Consumer Report, including information as to my character, general reputation, personal characteristics, and mode of living may be made. I authorize each former employer, school attended, and each person, firm, or corporation with information about me, to furnish at any time, any information which may be sought concerning me and my work habits, character or skill, and any other data required. Such information may be used in connection with this application or for purposes of complying with surety Company requirements or for any other legal, business or regulatory requirements that may be applicable to or imposed on the Company.

If I am accepted as a volunteer, I agree to comply with all the terms and conditions applicable to my status as a volunteer with the Company.

I accept the above terms:

Click "Submit" to send your application to Affinity. Thank you!