Volunteer Application | Hospice of the North Coast

Volunteer Application

I understand that if I choose to be a volunteer, Hospice of the North Coast may complete a criminal record and/or DMV checks and check references.

By submitting this form you are affirming that the information you have provided is true and correct.

First Name:
Last Name:
Email Address:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Drivers License Number:
Birthday (month and day only):
Emergency Contact:
Relationship:
Emergency Home Phone:
Emergency Work Phone:
Emergency Cell Phone:
Education & Special Skills:
Hobbies & Interests:
Occupation(s) (if retired, list former occupation):
Volunteer Experience:
Other languages spoken:
Pertinent health issues/Physical limitations:
Has a member of your immediate family or a significant other died in the past year?
Have you ever been a caregiver for someone who has died?
What motivated you to volunteer with Hospice and what do you hope to receive from the experience?
Areas of Interest:	Patient Care (required screening & completion of course training) Resale Shop Fundraising/Outreach Auxiliary
Administrative/Office Support:	Mailings Filing Receptionist Phones Typing Compiling Materials
Computer Skills:	Data Entry Word Processing Database
Other (explain):
Additional Skills:
Date available to start:
Available days & hours:
Are you available on a weekly basis?
How did you hear about Hospice of the North Coast?
Reference 1 First Name:
Reference 1 Last Name:
Reference 1 Email Address:
Reference 1 Address:
Reference 1 City:
Reference 1 Zip:
Reference 1 Home Phone:
Reference 1 Work Phone:
Reference 1 Cell Phone:
Reference 1 Relationship:
How long have you known this reference person 1:
Reference 2 First Name:
Reference 2 Last Name:
Reference 2 Email Address:
Reference 2 Address:
Reference 2 City:
Reference 2 Zip:
Reference 2 Home Phone:
Reference 2 Cell Phone:
Reference 2 Relationship:
How long have you known this reference person 2:
I agree, in typing my First and Last name (to the right of this statement), the information provided in this application is accurate and true to the best of my knowledge. Furthermore, Hospice of the North Coast may use this attestation statement as my electronic signature.

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