Volunteer Application

Thank you for your interest in becoming a VNA Hospice volunteer. Please complete this application. The following information will help us gain a better understanding of your abilities and interest, and will help us to best channel your energies and capabilities. Some of the questions may be personal and private, however, this information has proven most helpful to us in making volunteer assignments.

PERSONAL RECORD
Name
Organization
Street address
Address (cont.)
City
State
Zip/Postal code
Work Phone
Home Phone
Cell Phone
FAX
E-mail
EDUCATION
High School Name
Location (City/State)

Last Year Completed:
Did You Graduate?
Major or Specialty

COLLEGE

College Name
Location (City/State)
Last Year Completed
Did You Graduate?
Major or Specialty
TRADE SCHOOL
Trade School Name
Location (City/State)
Last Year Completed
Did You Graduate?
Major or Specialty
REFERENCES (Other than a family member)
Reference 1
Name
Address
Telephone Number
Reference 2
Name
Address
Telephone Number
You may check my references
A LITTLE ABOUT YOURSELF…
Are you employed?
If so, where?
Occupation
Do you have any special abilities, awards, hobbies?
Do you have a valid driver’s license?
Are you fluent in a language other than English?
If so, which?
Have you ever done any volunteer work?
If yes, please explain
How did you hear about VNA Hospice?
Why do you wish to become involved with VNA/Hospice?
Total number of hours per week you will be available for Hospice volunteering:
AVAILABILITY
Daytime
Evening
Weekend
Other
If other, please specify
Have you ever had experience with the terminally ill or are you presently caring for a terminally ill patient?
If yes, please explain
Has someone close to you recently died?
If yes, please explain
AREAS OF INTEREST
Patient home visits
Teen Programs
Special Events
Nursing home visits
Support groups
Office Work / Clerical
Bereavement
Other
If other, please specify
Have you ever been excluded, suspended, or otherwise sanctioned by any federal or state health care program?

I CERTIFY, by hitting ‘Submit Form,’ that this information is accurate and complete.

Things you should know…



  • All volunteers must have a criminal history investigation at no charge.

  • You will be asked to complete a Criminal History form. Your social security number will be required.

  • All volunteers at VNA of Erie County are required to have a yearly PPD (TB Test) at no charge to the volunteer.

  • Volunteers who visit patients must complete special training which is provided by VNA at no charge to the volunteer.