CONTACT INFORMATION
Name *
Name
Phone Number *
Phone Number
Address *
Address
VOLUNTEER DEMOGRAPHICS
Are you currently a student? *
School Address
School Address
Please list your school address
Are you a Veteran? *
Are you currently employed? *
If applicable, list your employer's name below.
List your current or most recent employer. *
List your current or most recent employer.
INTERESTS & AVAILABILITY
What Area Would You Like to Serve? *
Volunteer Positions *
Check all the positions that you're interested in.
Areas of Interest *
Check all that you have moderate to high expertise in.
We value your "why". Please share why you want hospice volunteering to be a part of your life.
Share how loss will lend to volunteer experience.
Let us know if your loss is recent, below.
Availability *
Please check all that apply to you and your schedule.
What time of day works best for you and your schedule? *
Please check all that apply to your and your schedule.
REFERENCES
References offer us valuable insight into who you are. Please provide three that can attest to your commitment and character.
Reference 1
Name *
Name
Address
Address
Phone
Phone
Reference 2
Name
Name
Address
Address
Phone
Phone
Reference 3
Name
Name
Address
Address
Phone
Phone
DISCLOSURES
Have you ever been arrested for, convicted of or pled no contest to a crime (other than minor offenses such as traffic tickets)? *
Do you use any chemical substances, to include illegal drugs that would in any way impair or limit your ability to perform the functions of your job with reasonable skill or safety? *
EMERGENCY CONTACT
Name *
Name
Address *
Address
Phone
Phone
Letting us know where you heard about us, improves our marketing efforts.
The information that I have provided on this application is accurate and true to the best of my knowledge. The persons, current and prior employers (if approved by me in the Employment History section) and other organizations or employers named in this application are authorized by me to verify the information I have provided. I am willing that a photocopy of this authorization be accepted with the same authority as the original. I hereby release from liability all representatives of Absolute Health Services for their acts performed in good faith and without malice in connection with evaluating my application, credentials & qualifications. I hereby release from any liability all individuals and organizations who provide information to the above in good faith and without malice concerning my professional competence, ethics, character and other qualifications. I understand that I am subject to Absolute Hospice's requirements for successful completion of our Volunteer acceptance process, which may include drug screens, background investigation, motor vehicle checks and reference checks. Note: Any contact with patient/family or patient medical file warrants a criminal background check per Medicare Hospice Regulations. My signature reflects that I have read, understood, and have agreed to these terms and conditions.

Thank you for submitting your application. Our volunteer coordinator will be in touch with you shortly.