Volunteer Application | Hospice of the Piedmont

Date*

Contact Information

Name*

First Last

Have you been fully vaccinated for the COVID-19 virus?*

Yes
No

Birthdate*

Are you at least 18 years of age?*

Yes
No

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Cell Phone

Work Phone

OK to call at work?

Yes
No

Email Address*

In case of emergency, please notify:

Emergency Contact Name*

First Last

Emergency Contact Phone*

Emergency Contact Relationship*

Employment History

Current Employment Status*

Full Time
Part Time
Retired
Not Employed
Student

Current/Former Employer Name

Current/Former Job Title

Employment Dates

Volunteer History

Agency or Facility Name

Title

Volunteer Dates

Agency or Facility Name

Title

Volunteer Dates

Volunteer Interests & Availability

Why do you want to become a volunteer with our Agency?*

In the last year, has an important person in your life died?*

Yes
No

If yes, what is your relationship to the person and when did they die?*

ONE YEAR RULE: We ask everyone to wait for at least one year after experiencing a loss before applying to become a volunteer. We have found it takes at least this long to live with one’s own grief before being able to help others.

Please indicate the branch you prefer to volunteer:*

Asheboro
High Point
No preference

Please indicate the area of volunteering which interests you most:*

Please indicate the time of the day/week that you expect to be most available to volunteer:*

Weekdays/daytime hours
Weekdays/evening hours
Weekends

How did you hear about our volunteer opportunities?

Google search/Hospice website
Volunteer Match, AARP or other volunteer site
Current/Former Hospice Volunteer or Staff
Community Speaking Engagement
School/University
Church or Civic group
Family member served by Hospice of the Piedmont
Other

Where did you hear about this volunteer opportunity?

Are you interested in volunteering your professional services?*

Yes
No

If yes, which field?

What professional service would you like to offer?

Please list any organizations, churches or clubs in which you are active.*

Are you a veteran?*

No
Yes

Which branch of military did you serve?

Army
Navy
Air Force
Marines
Coast Guard
National Guard

Have you ever applied for a job or been employeed by this organization before?*

Yes
No

Are you willing to commit to volunteering at Hospice of the Piedmont for a minimum of one year?*

Yes
No

Are you able to perform the essential functions of the position you are applying, either with or without reasonable accommodation?*

If no, please explain:

Background Check

Have you lived in NC for at least 5 years (or longer)?*

No
Yes

If no, we will ask that you complete a fingerprinting check as part of your background screening.

Have you ever been convicted of a criminal offense, felony or misdemeanor, and/or do you have any criminal charges pending?*

Yes
No

This question must be answered in order to be considered for acceptance as a volunteer, but a yes answer does not automatically disqualify a volunteer applicant from service to the agency. Any information related to this issue will be addressed on a case-by-case basis, and will remain confidential.

Please briefly explain.

Agreement

Hospice of the Piedmont, Inc. accepts volunteers without discrimination on the ground of sex, race, color, national origin, or creed. No otherwise qualified individual shall solely by reason of his/her handicap, be excluded from participation as a volunteer.

Agreement: I certify that answers given herein are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal employment, medical history, police record, and other related matters as may be necessary in arriving at a decision about volunteer placement. I hereby release employers, schools and other persons from all liability in responding to inquiries in connection with my application.

Signature

By typing your name below, you are electronically signing this application and confirming the statement above.

Volunteer Signature*

First Last

Submission Date*

Comments

This field is for validation purposes and should be left unchanged.

Volunteer Application Volunteer at Hospice of the Piedmont and Hospice of Randolph.

Volunteer Application Form

Contact Information

In case of emergency, please notify:

Employment History

Volunteer History

Volunteer Interests & Availability

Background Check

Agreement

Signature