Volunteer Application

Name*

First Last

Email*

Today's Date*

Address*

Street Address City State ZIP Code

Home Phone

Cell Phone*

Work Phone

Indicate Availability*

Days
Evenings
Weekdays
Weekends

Hours Per Week*

Have you, in the last 10 years, been convicted of a felony (excluding sealed/expunged convictions)?*

Yes
No

If you have ever been known by another name that we will need to know to verify your information, please indicate that name here:

First Last

Most recent employer’s name*

First Last

Address

Street Address City State ZIP Code

Occupation/Position*

Start Date

End Date

Check one box: I am*

Currently employed
Retired since

Year

Highest level of education received*

Certificate or Degree*

Previous relevant work/volunteer experience / skills that you possess*

Have you experienced the death of a friend/loved one?*

Yes
No

Date of most recent loss

Provide information for three (3) references (not family members) who can comment on your knowledge and skills

#1 Reference Name*

#1 Occupation*

#1 Relationship*

#1 Phone Number*

#2 Reference Name*

#2 Occupation*

#2 Relationship*

#2 Phone Number*

#3 Reference Name*

#3 Occupation*

#3 Relationship*

#3 Phone Number*

Please tell us how you learned of this volunteer opportunity*

My signature below certifies that I understand that all application data is subject to verification. I authorize Valiant Hospice to investigate my references, work records, education and other matters related to my suitability for volunteering. I certify that I have not knowingly withheld any information that might adversely affect my chances for volunteering and that the answers given by me are true and complete to the best of my knowledge. I understand that any omissions or misstatement on this application shall be grounds for rejection of this application.

Applicant signature*

Date*

Notice of Non-Discrimination: Valiant Hospice will not discriminate against anyone based on race, nationality, creed, color, age, sex, sexual orientation, or disability.

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