VNA & Hospice Volunteer Application All information supplied herein is confidential Today's Date MM slash DD slash YYYY Date of Birth* MM slash DD slash YYYY Name* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Work PhoneOther PhoneEmail* Emergency Contact Contact PhoneProfessional Licences, registrations and/or certificatesTypeIssued ByDate IssuedNumber Education / Special TrainingWork ExperienceList languages you speak, read and/or write other than English (optional)LanguageSpeak?Read?Write? Identified Areas of InterestWhat position(s) are you interested in volunteering for? Visiting Volunteer Office Volunteer Veteran Volunteer Pet Therapy Volunteer Complimentary Therapy Volunteer VNA Ambassador Hair Dresser/Stylist Music Therapy Weekly Deliveries Service Area (check all boxes that apply): Castroville / Moss Landing Carmel Carmel Valley Gilroy Gonzales Greenfield Hollister King City Marina / Seaside Monterey Morgan Hill Pebble Beach / Pacific Grove Prunedale Salinas Soledad Tres Pinos 1. Has anyone close to you died in the past year? Who? When? 2. How did you hear about our hospice volunteer program? 3. Why do you want to be a hospice volunteer? What do you expect to gain from this experience? 4. What qualities (skills, talents, knowledge, and experiences) do you think you can incorporate into your hospice volunteer work? 5. What are your thoughts and feelings about death?6. Have you ever been with someone at the time of their death? (If yes, please describe briefly)7. Have you ever provided care to anyone who was dying? (If yes, please explain)8. Some patients have serious physical limitations and/or altered appearances resulting from illness/treatment. How might this affect you? 9. What kind of feelings may come up for you in working with patients and/or support group members? 10. What are your sources of emotional support? 11. Please describe your own experience with grief and loss and how it has affected you.12. What else would you like us to know about you?Code of Ethics For VolunteersAs 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 interpret “volunteer” to mean that I have agreed to work without compensation in money but having been accepted as a volunteer worker, I expect to do my work according to standards set forth in the Volunteers Policies and Procedures. Declaration I hereby certify that statements made on this application are true and correct to the best of my knowledge. I understand that, by submitting this application, I authorize inquiries to be made concerning my employment and character for the purpose of determining my suitability as a volunteer. I affirm to have read the Code of Ethics for Volunteers and agree to abide by its regulations. I understand and agree with the requirements for hospice volunteers as specified below: Prior to volunteering with VNA and Hospice I will be required to do a drug screen and a background check screen Commitment to volunteering a minimum of 2-4 hours per week/ special services volunteers are required to volunteering a minimum of 2-4 hours a month Commitment to volunteer a minimum of 1 year Proof of current drivers license Proof of current auto-insurance Certificate ( if applicable) Proof of liability insurance ( massage therapist volunteers only) Access to computer and commitment to check emails on a daily basis Applicant Signature (type your full name)* Date* MM slash DD slash YYYY UntitledFirst ChoiceSecond ChoiceThird ChoiceSection Break Δ