State of the Heart Hospice

Volunteer Application Form

If you would like to become a volunteer, please fill out the below application in its entirety. * denotes a required field.

* Date of Application:
* First Name:
* Last Name:
Former Name:
* Address:
* City:
* State:
* Zip:
* Home Phone:
Other Phone:
* E-Mail:
 

Experience:
What type of work have you done in the past?
Homemaker
Factory/Labor
Professional (please specify)
Other (please specify)
 
Have you done any volunteer work?
Yes (please specify)
No
 
Have you ever volunteered with us before?
Yes
No
If yes, when?
 
Are you available to volunteer on:
Weekends: Yes No
Evenings: Yes No
Daytime: Yes No
   
Have you been convicted of a felony within the last seven years? (Conviction will not necessarily disqualify an applicant from volunteering)
Yes No
If yes, please explain:
We consider applications for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, or handicap, or any other legally protected status.
 

Special Skills and Qualifications:
Summarize special volunteer related skills and qualifications: