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Goodwin Hospice Volunteer Application
Date
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First Name
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Last Name
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Street Address
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Address Line 2
City
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State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
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Phone Number (cell)
Phone Number (other)
Email Address
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Work experience:
Education/Training
Previous volunteer experience
Have you ever been convicted of a crime, excluding traffic offenses?
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Yes
No
If yes, please describe
Do you have any limitations (physical or other) which might affect your ability to volunteer?
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Yes
No
If yes, please describe
Why do you want to be a hospice volunteer?
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Has someone close to you died in the last year?
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Yes
No
If yes, state relationship
How did you learn about our volunteer program?
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Emergency Contact Name:
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Phone:
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Can you volunteer an average of one hour per week? (Volunteer time commitment may vary depending on the volunteer position.)
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Yes
No
Can you promise a full year of service?
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Yes
No
Can you participate an additional 2 hours at least twice a year in training seminars or group meetings?
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Yes
No
If you answered NO to any of the above, please explain
Indicate the times when you are available to volunteer
Are there any experiences, skills or qualifications which you feel would be especially helpful for hospice volunteer work?
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Do you speak any languages other than English? If so, please list them and your fluency level.
References (Please provide two references that know of your skills related to volunteering, hospice work, and/or interacting with older adults)
First Name
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Last Name
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Phone Number
How long has this person known you, and in what capacity?
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Email Address
First Name
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Last Name
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Phone Number
Email Address
How long has this person known you, and in what capacity?
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The facts set forth in my application for hospice volunteering are true and complete. If accepted as a hospice volunteer, I agree to abide by the directions, rules and policies of Goodwin Hospice regarding volunteers.
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Yes
No
Signature (Use your computer mouse or laptop touchpad to sign your name)
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