Volunteer Application Form

First Name (required)

Middle Name

Last Name (required)

Address (required)

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

ZIP Code (required)

Your Email (required)
Primary Phone # (required)

Briefly describe the type of work you do:

Total number of hours per week you could be available for hospice volunteering:

Foreign languages spoken:

Age Range:

15-1718-3031-4041-5051 and up

How did you hear about us?

Why do you wish to be involved in hospice?

Have you had experience with the terminally ill?

YesNo
(If yes, please explain)

Has someone close to you died within the past year?

YesNo
(If yes, please note who)

Do you have available transportation for your volunteer work?

YesNo

Do you have a valid California driver’s license?

YesNo

Do you have automobile liability insurance?

(Auto insurance is required if you use your car
for hospice work.)

YesNo

Have you been convicted of a felony within the last 7 years?

(Conviction will not necessarily disqualify you from volunteering.)

YesNo
List experiences you believe would be helpful to you in hospice volunteering, i.e., schooling, work, volunteer experience, office skills, arts and crafts, etc.

(Please check areas of interest)

Direct:

Indirect: