VOLUNTEER APPLICATION 238 Merrimac Court, PO Box 838 Prince Frederick, MD 20678 Thank you for your interest in becoming a volunteer with Calvert Hospice. This application has been developed specifically for our program. You may find that some of the questions are personal in nature, but we have found this information helpful in making volunteer selections and assignments. All information provided is confidential. FIRST NAME: LAST NAME: EMAIL: HOME PHONE: CELL PHONE: STREET ADDRESS: CITY : STATE: ZIP: EMPLOYMENT HISTORY COMPANY ADDRESS POSITION DATES COMPANY ADDRESS POSITION DATES MILITARY HISTORY BRANCH DATES VOLUNTEER HISTORY ORGANIZATION VOLUNTEER POSITION ORGANIZATION VOLUNTEER POSITION ORGANIZATION VOLUNTEER POSITION
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VOLUNTEER APPLICATION · 2014-10-01 · VOLUNTEER APPLICATION 238 Merrimac Court, PO Box 838 Prince Frederick, MD 20678. Thank you for your interest in becoming a volunteer with Calvert
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VOLUNTEER APPLICATION 238 Merrimac Court, PO Box 838 Prince Frederick, MD 20678
Thank you for your interest in becoming a volunteer with Calvert Hospice. This application has been developed specifically for our program. You may find that some of the questions are personal in nature, but we have found this information helpful in making volunteer selections and assignments. All information provided is confidential.
FIRST NAME: LAST NAME:
EMAIL: HOME PHONE:
CELL PHONE:
STREET ADDRESS:
CITY:
STATE: ZIP:
EMPLOYMENT HISTORYCOMPANY ADDRESS
POSITION DATES
COMPANY ADDRESS
POSITION DATES
MILITARY HISTORYBRANCH DATES
VOLUNTEER HISTORYORGANIZATION VOLUNTEER
POSITION
ORGANIZATION VOLUNTEER POSITION
ORGANIZATION VOLUNTEER POSITION
RELEVANTBACKGROUND (MAY INCLUDE
EDUCATION, COMMUNITY SVC, FAMILY
EXPERIENCE)
Why do you wish to become a
hospice volunteer?
Do you have health / physical
problems that limit your ability to
perform required tasks? Please
explain.
BEREAVEMENT HISTORYDECEASED'S
NAMEDATE OF
DEATH
HOSPICE PATIENT?
YES OR NO
DECEASED'S AGE AT DEATH
CAUSE OF DEATH
RELATIONSHIP
DECEASED'S NAME
DATE OF DEATH
HOSPICE PATIENT?
YES OR NO
DECEASED'S AGE AT DEATH
CAUSE OF DEATH
RELATIONSHIP
ARE YOUBILINGUAL?
YES
NO
WHAT LANGUAGE?
DO YOU POSSESS A VALID DRIVER'S
LICENSE?
YES
NO
DRIVER'S LICENSE NUMBER & STATE
DO YOU HAVE ACCESS TO A CAR?
YES
NO
AUTO INSURANCE CO. & POLICY
NUMBER
TIMES YOU'RE AVAILABLE FOR
VOLUNTEER WORK
DAYSWEEKENDSEVENINGS
HAVE YOU EVER BEEN CONVICTED
OF A CRIME?
YESNO
HAVE YOUEVER HAD
YOUR LICENSE REVOKED?
YESNO
ARE YOU CURRENTLY UNDER INVESTIGATION OR PENDING
CHARGES?
YESNO
Please share the names and contact information of three people we can contact for a personal reference.
NAME: PHONE OR EMAIL:
NAME: PHONE OR EMAIL:
NAME: PHONE OR EMAIL:
____ I understand that Calvert Hospice recruits volunteers and employees, and provides care to patients without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age, or disability. _____ I understand that Calvert Hospice's drug and alcohol policy prohibits the use of alcohol or illegal drugs while working or volunteering.