Volunteer Application

Hospice of the Piedmont considers volunteer applicants for all positions regardless of race, color, religion, creed, gender, national origin, age, disability, marital, or veteran status, or any other legally protected status.

Name*

First NameLast Name

Have you been fully vaccinated for the COVID-19 virus?*

YesNo

Phone Number:*

Area CodePhone Number

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail Address:*

example@example.com

How did you hear about us?*

Newspaper AdFacebookGoogle SearchOther (explain below)

Other:

Are you a Veteran?*

YesNo

Branch of Service:

Military Branch

Are you a student?*

YesNo

Are you a certified massage therapist looking to offer your services?*

YesNo

Are you a certified Reiki therapist looking to offer your services?*

YesNo

Are you the owner of a certified pet therapy dog looking to offer that service?*

YesNo

Area(s) of interest:*

Patient InvolvementJourneys Camps (for bereaved children)Administrative

Most Recent Work History (describe duties)*

Other hobbies, interests, skills or experiences you bring to hospice work.*

Other organizations or civic groups you feel are pertinent.*

Why do you wish to volunteer with Hospice of the Piedmont?*

Do you have any physical limitations that would affect your ability to work with patients/families?*

What losses have you experienced? When did these losses occur? *

How do you handle/cope with stress?*

Date of Birth

Ethnicity

References: List two (3) persons to whom you are not related and who have known you for several years, preferably people familiar with your work skills.

Reference 1:

Name: *

First NameLast Name

E-mail Address:*

example@example.com

Mailing Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Reference 2:

Name:*

First NameLast Name

E-mail Address:*

example@example.com

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Reference 3:

Name:*

First NameLast Name

E-mail Address:*

example@example.com

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Ethnicity

APPLICANT'S STATEMENT

I certify that answers given herein are true and complete. I authorize investigation of all statements contained in this volunteer application as may be necessary in determining acceptance in a volunteer capacity. In the event of becoming a hospice volunteer, I understand that false or misleading information given in my application or interview(s) may result in termination of volunteer status. I understand, also, that I am required to abide by all rules and regulations of Hospice.

Name*

First NameLast Name

Date*

Date