All fields are required. If a question does not apply to you, please enter NA.

Referral Source
Hospice WebsiteHospice Flyer or BrochureHospice Community EventRadioNewspaperFriend/RelativeFacebook/Other Social MediaI am a Friend/Relative of a Hospice PatientOther

Hospice Community Event

Name of Friend/Relative

Name of Friend/Relative who is a Hospice Patient

Your name
First:
Middle:
Last:
Address Street:

City:
Zip:
County:
Contact Information

Email

Preferred Phone -
( ) -
Secondary Phone -
( ) -
Seasonal Information

Do you reside outside of Florida during the year

Months you reside in Florida
JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberAll Year

Seasonal Address
Street:

City:
State:
Zip:

Seasonal Phone

( ) -

Emergency Information
Emergency Contact Name
Emergency Contact Phone
( ) -
Languages/Education

Languages other than English

Student
Education/Grade
Employment
Retired
Occupation/Former Occupation:

Employment Status
Employer Name

Are you a Veteran?
If yes, Branch:
References

List 3 personal references other than family members:


Reference 1

Name:
Phone
( ) -
Street (optional):
City (optional):
State (optional):
Zip (optional):

Reference 2

Name:
Phone
( ) -
Street (optional):
City (optional):
State (optional):
Zip (optional):

Reference 3

Name:
Phone
( ) -
Street (optional):
City (optional):
State (optional):
Zip (optional):
Skills/Limitations

Please check your skills and abilities

ClericalComputerCraftsFund RaisingMassagePublic SpeakingTeachingOther


Limitations
If yes, please explain:

Interests

Please select the Hospice activities you are interested in

Administrative SupportBulk MailCommunity EventsCourierFund RaisingGrief SupportPatient SupportThrift Shoppe
Availability

Days Availabile

SundayMondayTuesdayWednesdayThursdayFridaySaturday

Times Available

Personal
Date of Birth
  
Are you fearful of pets?
Do you smoke?

Club/Organization Memberships
Religious Affiliation

Have you experienced the death of someone close to you within the last year?
If yes, please explain:


Have you been convicted of a crime in the past ten years, excluding misdemeanors and summary offenses, which has not been annulled, expunged or sealed by the court?
If yes, describe:

Verification and Submission

I hereby certify that the above information is true and complete to the best of my knowledge. I give permission for Hospice of Citrus and the Nature Coast to contact any reference provided. I understand that Hospice of Citrus and the Nature Coast will conduct a Level 2 Background Screening for all volunteers who provide personal care services or have access to client property, funds or living areas. I understand that misstatement or omission of fact may result in my dismissal.

By initialing here , I confirm that I have read the above statement and agree that it is true.

Notice: If applicant is under the age of 18, a parent or guardian must co-sign application at meeting with Volunteer Services Manager.