Volunteer Application

Volunteer Application
Applicant Name*
Address*

Address

Street Address Line 2

CityState

Zip
Phone*
E-mail Address*
example@example.com
I live in or close to: (please choose all that apply)

TucsonGreen ValleySierra Vista
Person to be notified in an emergency
Name*
Phone*
Address*

Address

Street Address Line 2

CityState

Zip
Education/Special Training
Work Experience*
Other special services: (i.e., manicurist, hairdresser, massage therapy)

YesNo
Other special services: (i.e., manicurist, hairdresser, massage therapy)
TWO PERSONAL REFERENCES: (excluding family members
Name of Personal Reference #1*
Phone for Personal Reference #1*
E-mail Address for Personal Reference #1*
example@example.com
Name of Personal Reference #2 *
Phone for Personal Reference #2*
E-mail Address for Personal Reference #2*
example@example.com
Are you 16 years or older?*

YesNo
Do you have access to reliable transportation?

YesNo
Do you know a language other than English?*

YesNo
Language #1
Language #1

SpeakReadWrite
Language #2
Language #2

SpeakReadWrite
How did you hear about our Hospice Volunteer Program?
Why do you want to be a hospice volunteer?
What qualities (i.e. skills, talents, knowledge and experiences) do you feel you can incorporate into your hospice volunteer work?
What are your thoughts and feelings about death?
Have you ever been with someone at the time of their death?

YesNo
If yes, please describe briefly:
Have you ever provided care to anyone who was dying?

YesNo
If yes, please describe briefly
When thinking of your own death, what words best describe death to you?

I do not think about my own deathSorrowfulNaturalFrighteningPainfulLonelyJoyfulPeacefulHeavyDarkOther
Comments
Applicant’s Signature

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Date

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Date
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