Indirect Service Volunteer Application

Hospice of St. Lawrence Valley Indirect Volunteer Application

All Hospice of St. Lawrence Valley volunteer applicants are considered without regard to race, religion, color, sex, gender identity, sexual orientation, national origin, ancestry, citizenship status, uniform service member status, marital status, pregnancy, age, protected medical condition, genetic information, disability, or any other protected status in accordance with all applicable federal, state and local laws.

All volunteers are required to be vaccinated against COVID-19 and must be able to provide a copy of their vaccination card.

Date(Required)

Demographic and Contact Information

Name(Required)

First Last

Preferred Name/ Pronouns

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone(Required)

Work Phone

Cell Phone

Email(Required)

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Relationship(Required)

Background Information

Do you have friends or relatives currently working or volunteering for us?(Required)

Yes

If Yes, Name(s)

If chosen as a volunteer, can you furnish proof that you are over 18 years of age?(Required)

Yes

Do you have a reliable means of transportation?(Required)

Yes

When would you be available to volunteer? (Please check all that apply)(Required)

Days

Evenings

Weekends

Summer Only

Winter Only

All Year

Have you ever pled guilty or “no contest” to, or been convicted of a misdemeanor or felony?(Required)

Yes

If yes, please give date(s) and details:

Work Experience

List your present or previous employers starting with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, religion, gender, national origin, disability, or other protected status.

Name of Employer(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Employment Dates(Required)

From

Immediate Supervisor(Required)

Duties(Required)

Reasons for leaving(Required)

Second Employer Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Employment Dates

From:

To:

Immediate Supervisor

Duties

Reasons for Leaving

Education

High School(Required)

Name

Location

Graduation Date

College

Name

Location

Graduation Date

Graduate School

Name

Location

Graduation Date

Volunteer Skills/ Interests

Please tell us about any skills you have that you would like to share in your volunteer service

List

Language(s)

Computer Skills

Certifications

Hobbies/Leisure Activities

Arts & Crafts

Music

Other

Please Select the types of volunteer work you are interested in:

Data Entry

Mailings

Copy/Assembling Packets

Community Events

Fundraising

Memorial Garden Assistance

References

Reference Name 1(Required)

First Last

Home/Cell

Work

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation

Reference Name 2(Required)

First Last

Home/Cell

Work

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation

Reference Name 3(Required)

First Last

Home/ Cell Phone

Work Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation

Standards of Contact

As a volunteer, I realize that I am subject to the Standards of Conduct similar to that which binds the professional in the field in which I work. I, like them, assume certain responsibilities and expect to account for what I do in terms of what is expected of me. I understand that any information that is disclosed to me while assisting the hospice is confidential I interpret “volunteer” to mean that I have agreed to work without compensation in money but having been accepted as a volunteer, I expect to do my work according to the standards set forth in the Standards of Conduct.

Volunteer Applicant’s Statement and Agreement

I understand that HOSPICE may obtain Public Records about me as part of a background investigation and that I may waive my right to receive a copy of such Public Records by checking this box ( ). I hereby state that all the information that I have provided on this application or any other documents completed in connection with my volunteer application, and in any interview, is true and accurate. I have withheld nothing that would, if disclosed, affect this volunteer application unfavorably. I understand that if I am accepted as a volunteer and any information provided to HOSPICE is found to be false or incomplete in any respect, my volunteer relationship with HOSPICE may be terminated regardless of the time elapsed before discovery. I affirm to have read the code of ethics for volunteers and agree to abide by its regulations. I agree to respect the confidentiality of any client information I may acquire during my volunteer activities. I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE STATEMENTS AND UNDERSTAND THE SAME.

Signature(Required)

Date(Required)

Name

This field is for validation purposes and should be left unchanged.