Volunteer Application

Download the Hospice Volunteer Application.

Personal Data
First Name *
Middle Initial *
Last Name *
Address *
City *
State *
Zip *
Phone *
Cell Phone
Work Phone
E-mail address *
Spouse First Name
Social Security Number
Spouse Last Name
Names of children
Have you ever been convicted of a felony?
Felony conviction *
Birthdate *
Choose Date
Sun. Mon. Tue. Wed. Thu. Fri. Sat.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
T-shirt size *



Person to be notified in an emergency:
Contact's First Name *
Contact's Last Name *
Address *
City *
State *
Zip Code *
Cell/Work/Home Phone *
Health
Do you have any health-related or physical limitations, which would limit your work as a Hospice volunteer?
Health Status *
If yes, please explain.
References
First Name of Reference *
Last Name of Reference *
Address *
City *
State *
Zip Code *
Cell/Work/Home Phone *
Relationship to you *
First Name of Reference *
Last Name *
Address *
City *
State *
Zip Code *
Cell/Work/Home Phone *
Relationship to you *
Employment History
Organization Name
Employer Address *
City *
State *
Zip Code *
Work Phone *
Volunteer History
Volunteer Organization
Volunteer Address *
City *
State *
Zip Code *
Work Phone *
Type of Work
Type of volunteer work

Authorization to take Photographs


I hereby consent to allow a representative of Hospice of North Central Oklahoma, Inc. to photograph me (and/or my family member) for the purpose of educating the communities that we serve about our programs. I understand that this will allow Hospice of North Central Oklahoma, Inc. to share these photographs with the public through marketing materials including but not limited to, the local newspapers, hospice website, brochures, media sources, and display board.
Yes, I agree. *

Releases and Applicant’s Signature


In connection with my application for becoming a hospice volunteer, I understand that investigative background inquires may be made on me including criminal convictions, motor vehicle records and reference checks. I authorize without reservation, any party or agency contacted to furnish the above mentioned information and release all parties involved from liability and responsibility for doing so.

I understand that any false information is grounds for rejection or termination of volunteer status.

I hereby consent to Hospice of North Central Oklahoma, Inc. and/or any of the agents obtaining the above information. This authorization and consent shall be valid in original, fax, or copy form.

I am willing to make a commitment of my time and energy to Hospice of North Central Oklahoma, Inc. as an active volunteer.
Yes, I agree. *

Code of Ethics for Volunteers


As a volunteer, I realize that I am subject to a code of ethics similar to that which binds the professional in the field in which I work. I, like them, assume certain responsibilities and expect to account for what I do in terms of what is expected of me.

I understand that any information that is disclosed to me while assisting the hospice is confidential.

I interpret “volunteer” to mean that I have agreed to work without compensation in money. Having been accepted as a volunteer worker, I expect to do my work according to the standards set forth in the Volunteer Policies and Procedures.
Yes, I agree. *

Declaration

I hereby certify that the statements made in this application are true and correct to the best of my knowledge. I understand that, by submitting this application I authorize inquires to be made concerning my employment, character and public records for the purpose of determining my suitability as a volunteer. I affirm that I have read the volunteer Code of Ethics and agree to abide by its regulations. I agree to respect the confidentiality of any client information I acquire in the course of my volunteer activities with Hospice of North Central Oklahoma, Inc.
Yes, I agree. *

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