Volunteer Application

Name
Address
City
Zip
Home Phone
Work Phone
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E-mail Address
Employment
Position
Hours
Date of Birth

VOLUNTEER INTERESTS

Why are you interested in taking the Hospice Volunteer course?

Hospice utilizes volunteers in many areas. What are your interests? (Please check all that apply.)

Office/Clerical Special Events Speaker's Bureau Health Fairs Patient/Family Children's Bereavement Adult Bereavement "Watchman Volunteer" Faith Based Volunteer Program

EXPERIENCE

Please list previous volunteer experience (organization, location, dates, hours served, type of work).

List any other experiences or skills related to your volunteer interests:

What experiences have you had with people who are seriously ill?

Do you or does anyone in your family currently have cancer or a serious illness?

Have you had a death in the family in the past twelve months? If so, can you please elaborate?

Please list which Volunteer areas you want to work in (geographically i.e. Summerville, Mt. Pleasant, Goose Creek, Downtown, West Ashley, James Island, etc.)

Are you willing to travel to other areas if there was no one else available?

Is there any diagnosis a patient may have that you are not willing to work with? (if so, please explain)

Availability (i.e. weekdays, weekends, evenings)

REFERENCES (NO RELATIVES)

Name: Address: Phone #: Name: Address: Phone #: Name: Address: Phone #:

Disabilities or Special Needs:

Have you ever been convicted of any crime other than a traffic violation?

Yes No If yes, explain:

PERSONAL INTERESTS

Organizations B'nai Birth Eastern Star Elk's Lodge Exchange Club Junior League Knights of Columbus Lions Club Order of Masons Optimist Retired Firepersons Retired Policepersons Religious (explain) Rotary Sertoma Veteran Other (explain) Skills Carpentry Electrical Plumbing Gardening Sewing Calligraphy Pet Care Hair Care Nail Care House Cleaning Reading Writing Letters Speak a foreign language (explain) Other (explain) Office Skills Clerical Typing Word Processing Data Entry Reception Bulk Mailing Questionnaires Record Keeping Filing Hobbies/ Interests Music Singing Drawing/Painting Reading Writing Sewing Gardening Crafts Socialization Cooking Pets Sports (please list) Watching television Shopping Scrapbooking Other (explain)

I understand that Hospice of Charleston reserves the right to accept or reject my application in its sole discretion and that the above statements made in this application are true.

I AUTHORIZE HOSPICE OF CHARLESTON TO CONDUCT A CRIMINAL RECORD SEARCH TO VERIFY MY SUITABILITY FOR VOLUNTEER SERVICES.

This information will be kept confidential. It will help us in making your volunteer experience with Hospice of Charleston more enjoyable. Please feel free to call us at (843) 529-3100 if you have any questions or need additional information.