1. PERSONAL INFORMATION:

First and Last Name:

Street Address:

City:

State:

Postal Code:

E-mail Address:

Telephone #:

Work Telephone #:

Cell Phone #:

Best time to reach you by phone:

2. REASON YOU ARE APPLYING FOR VOLUNTEER WORK:

Personal Enrichment

Gain/practice skills; what skills?

Other reason; please explain:

How did you hear about this volunteering opportunity?

3. EXPERIENCE WITH SERIOUS ILLNESS

The last death of someone close to me was:
Less than one year ago
one to five years ago
five or more years ago
Relationship:

Why have you chose to volunteer with Genesys Hospice?

Have you ever been with someone at the time of their death?

4. AVAILABILITY:

Length of time available to volunteer?

One Year
More than One Year
Other  If Other, please specify:

How often:

Weekly
Twice a Month
Monthly
Other  If Other, please specify:

Select the times you would be available to volunteer by clicking the corresponding box.

Please check your area(s) of interest:

Respite Care
Spiritual Care
Bereavement Care
Clerical/Office Work
Receptionist

5. VOLUNTEER EXPERIENCE:

Please list any current and prior volunteer experience: including clubs, church, school projects...

Hobbies / special interests:

6. EMERGENCY CONTACT:

Name:

Street Address:

Relationship:

GENERAL INFORMATION:

7. Are you under 18 years of age? Yes No

if Yes, please list your age and birth date:

8. Have you ever volunteered or been employed at a Genesys Health System Organization?
Yes No

If Yes, please indicate position:

9. Have you ever been convicted of a crime? Yes No

If Yes, please complete the following:

Please Explain

10.PERSONAL REFERENCES: Please list at least two references other than relatives or employees (You must have completemailing address, including zip code.)

ACKNOWLEDGEMENT:
I hereby affirm that the information provided on this application is true and complete to the best of my knowledge. I understand a misrepresentation of facts constitutes cause of separation.

If placed I will volunteer on a regular basis, be dependable, and honor all Genesys Health System and volunteer policies and guidelines. I hereby authorize present and former employers, associates, schools, credit organizations, law enforcement agencies, military organizations, and/or other persons to provide Genesys Health System with any information which may aid in determining my suitability for volunteering. Additionally, I release those individuals and/or organizations contacted from all liability whatsoever for issuing the requested information, and hereby waive my right to receive written notice of any such information provided. I also hereby release Genesys Health System, its affiliates and employees from any and all liability and damages for requesting, releasing and using information concerning me, my work and performance record.

It is clearly understood that there is no employer/employee relationship and that as a support volunteer I am not entitled to compensation or fringe benefits of any kind for voluntary services.


A telephone interview will be scheduled when your completed application is recieved