MSMH - Hospice of St. Mary's Volunteer Application Form - 4882092

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Hospice of St. Mary's Volunteer Application

I acknowledge and understand I am filling out an application for volunteering at Hospice of St. Mary's, located in Callaway, MD in St. Mary's County.

Personal Data

Date*

Name*

First Name

Initial (optional)

Last Name

Preferred name*

Mailing address*

Address Line 1

Address Line 2

City

State

ZIP Code

Home telephone*

Mobile telephone*

Work telephone*

Email Address*

Emergency contact name*

First Name

Last Name

Emergency contact number*

Community clubs and organizations*

Have you ever been convicted of a felony?*

Yes No

If yes, describe when the conviction occurred, the facts and circumstances and any other pertinent information. Do not list any criminal charges for which the records have been stricken. *

(A criminal offense will not necessarily bar you from serving as a volunteer.)

Month and day of birthday*

I am age 18 or older*

Yes No

Are you a veteran?*

Yes No

Branch and year*

Are any accommodations needed?*

Yes No

If yes, please state accommodations required*

References

Please list three references who are not relatives.

Name*

First Name

Last Name

Relationship*

Length of time known*

Phone *

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Country

Name

First Name

Last Name

Relationship

Length of time known

Phone

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Country

Name

First Name

Last Name

Relationship

Length of time known

Phone

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Country

Hospice experience

Have you ever been employed or served as a volunteer here before?*

Yes No

If yes, what year?*

Under what name?*

Please list any Hospice training you may have with locations and dates*

Have you had any experience with a terminally ill person?*

Yes No

If yes, please describe*

Describe any grief and/or bereavement experience*

Why do you want to volunteer for Hospice?*

What do you believe you can offer Hospice of St. Mary’s? *

Applicant's Statement

I certify that the answers given to this application are true and complete and I authorize Hospice of St. Mary’s to investigate any or all statements made herein. I understand that any falsification or omission of information will result in rejection and /or immediate termination. I agree that my volunteering, and the terms and conditions thereof, may be modified or terminated at any time at the discretion of Hospice of St. Mary’s. I agree as a condition of volunteering to conform to Hospice rules and regulations.

I understand that volunteering is contingent upon favorable results of any and all tests such as, but not limited to:

- Successful completion of a physical assessment conducted by Hospital staff including drug testing

- Receipt of acceptable references from previous employers or personal references

- Criminal background check

- Proof of valid auto insurance and driver’s license

- An interview to determine appropriateness for a volunteer position at Hospice of St Mary’s

I also understand that my service as a volunteer to Hospice of St. Mary’s may be terminated at any time, without prior warning by the Director of Hospice.

Applicant's signature*

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Date*

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Hospice of St. Mary's Volunteer Application

Personal Data

Education/Skills

References

Volunteer availability

Hospice experience