Volunteer Application

PLEASE CHECK THE POSITION YOU ARE INTERESTED  

HOSPICE                              BEREAVEMENT                              CAREGIVERS

OFFICE                                 FUNDRAISING                                BOARD MEMBER

NAME:         

ADDRESS:       CITY:     

ZIP CODE:         HOME TELEPHONE:      

IN CASE OF EMERGENCY PLEASE NOTIFY:    

RELATIONSHIP:   

HOME TELEPHONE:          BUSINESS TELEPHONE:     

ADDRESS:       CITY/ZIP CODE:   

CURRENT EMPLOYMENT INFORMATION:  

EMPLOYER NAME:   

ADDRESS:         CITY:    

BUSINESS TELEPHONE:     POSITION:   

HOURS WORKED:         MAY WE CALL YOUR WORK            YES NO

EDUCATION  

HIGHEST GRADE LEVEL:    

DEGREES OBTAINED:         

AVAILABILITY :(PLEASE CHECK)

DO YOU HAVE (PLEASE CHECK)

OUR CLIENTS REQUIRE TRANSPORTATION SO COULD YOU PLEASE ANSWER THE FOLLOWING 

QUESTIONS REGARDING YOUR DRIVING RECORD:

HAVE YOU HAD ANY TRAFFIC VIOLATION IN THE LAST 5 YEARS: NO YES IF YES PLEASE EXPLAIN:   

HAVE YOU HAD TRAFFIC ACCIDENTS IN THE LAST 5 YEARS:    NO YES     IF YES PLEASE EXPLAIN:   

SPECIAL SKILLS AND/OR INTERESTS: (PLEASE CHECK)  

CLERICAL WORK                                            CALLIGRAPHY                          MUSIC    

ACCOUNTING/BOOKKEEPING                    SEWING                                       CRAFTS

HOBBIES -- Specify:   

LANGUAGES -- Specify:   

HEALTH QUESTIONNAIRE:  

HAVE YOU HAD ANY SERIOUS ILLNESS IN THE LAST 5 YEARS:  IF SO PLEASE DESCRIBE:  

DO YOU HAVE ANY PHYSICAL LIMITATIONS THAT WOULD BE A HINDRANCE TO YOU IN YOUR 

VOLUNTEER ROLE:  IF SO PLEASE DESCRIBE:

AS PART OF OUR ADMISSION CRITERIA, YOU WILL NEED A TUBERCULOSIS TEST.  WOULD THIS 

BE OKAY WITH YOU:  YES NO

I hereby certify that the above information is true and complete to the best of my knowledge.  I realize this information is confidential and may be used to determine my eligibility to volunteer.  I authorize 

PATHWAYS VOLUNTEER HOSPICE to make any inquires regarding these facts.  

I also agree to submit to any examinations which may include chest x-ray, appropriate laboratory tests, 

and/or immunizations which may be necessary as part of my volunteer service.  I also authorize my 

physician to furnish information regarding my current health.