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Volunteer Application

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
Address Street:

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:

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

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.