hospice volunteer application

(* denotes required information)

Personal Information

Name *
Street Address *
City *

Zip Code *
Birthdate *

Phone/Fax/Email

Home Phone *
Work Phone
Mobile Phone
Fax
Email Address

Employment Information

Employer
Job Title

Family Information

Marital Status
Spouse's Name
Children (names and ages)

Skills and Hobbies

Interests, hobbies, skills
Foreign languages you speak

Volunteer Information


Areas of volunteer service that interest you:
(check all that apply)

 patient support
 office support
 bereavement support
 bakery team
 special events
 watchman
 speakers bureau
Preferred geographic area to volunteer in:
Approximate hours available each week:
Past bereavements (include relationships and dates):
How did you hear about the volunteer opportunities with St. Francis Hospice?
Why do you want to be a St. Francis Hospice volunteer?

Volunteer Experience

Organization Name
Beginning Date
Ending Date
Duties Performed
Organization Name
Beginning Date
Ending Date
Duties Performed
Organization Name
Beginning Date


Physical limitations
Medical concerns:

Emergency Notification
Notify in case of emergency:

Name *
Phone Number *

I authorize St. Francis Hospice to make inquiries of my personal, employment history, and obtain a medical clearance form completed by my physician. I hereby release employers, schools, or persons from all liability in responding to inquiries in connection with this application.

I also authorize St. Francis Hospital Hospice to conduct a background check on me according to the Pre-Employment Background Checks policy. I understand that my volunteer work may not begin until satisfactory background information has been received. I also understand that St. Francis Hospital Hospice will assume all costs of this background research.

I understand that confidentiality must be maintained by every hospital employee and volunteer. Under no circumstances may information concerning patients and their families be repeated to anyone except those authorized to receive such information.

I agree to abide by the policies and procedures of St. Francis Hospice.

 I agree with the above statements. *
* required fields
Bon Secours International| Sisters of Bon Secours USA| Bon Secours Health System