*Indicate required fields

 

*First Name:   ______________________________________________________________

 

*Last Name:   ______________________________________________________________

 

*City:  __________________________  *State:  _____________  *Zip:  ______________

 

*Home Phone Number:  ________________________________

 

Work Phone Number:  ________________________________

 

*email:  ________________________________

 

Are you 18 Years of age or older?   Yes    No

Education:   High School Graduate Some college  College Graduate   Post Graduate

 

Degrees Earned:  ____________________________________________________________

 

Occupation:  ________________________________________________________________

 

*Present/Previous Employment:  _____________________________________________

 

Present Volunteer Service:   __________________________________________________

 

Past Volunteer Service:   _____________________________________________________

 

Special Skills or Training:   ____________________________________________________

 

Do you have reliable transportation?   Yes    No

 

If interested in position that involves driving, do you have a valid drivers licenser?

   Yes    No

Drivers License #:  ________________________________

 

Have you ever been convicted of a crime?  Yes    No

If yes, explain:  ____________________________________________________________

 

Are there any felony convictions pending against you?   Yes    No

If yes, explain:  ____________________________________________________________

We are required by law to conduct a criminal background check on all employees/volunteers

 

How did you learn about our volunteer program?   _____________________________

 

*Has someone close to you died within the last year?  If so, what was your relationship to them and when did they die?  _______________________________________________

 

 

 

 

*Briefly explain your interest in volunteering with Hospice Care of Southwest Michigan:  __________________________________________________________________________

 

Areas of Interest:  Please check your preferences.

Friendly Visitor/Companionship Office/Clerical  Flowers/Gardening Massage Therapy  Maintenance  Errands/Transportation

Barber/Beautician  Grief Support   Community Relations/Marketing Homecare/Respite Music Therapy Group facilitation/Support

 

 

Please indicate day(s) and time(s) you may be available to volunteer.  We understand changes may be necessary.

 

 

                      Sun Mon Tue Wed Thu Fri Sat

    Morning                          

 Afternoon                          

     Evening                          

 

 

Personal References: 

Please list 3 people who have known you for more than one year and are not relatives.  We must have complete addresses.

 

Name One:  ________________________________

Address, City, State, Zip:  ________________________________________________

Phone:  ________________________________

 

Name Two:  ________________________________

Address, City, State, Zip:  ________________________________________________

Phone:  ________________________________

 

Name Three:  ________________________________

Address, City, State, Zip:  ________________________________________________

Phone:  ________________________________

 

 

Please fax or mail this form to our agency:

 

Hospice Care of Southwest MI

222 North Kalamazoo Mall

Suite 100

Kalamazoo, Michigan 49007

Fax: 269-345-8522

 

Volunteer Signup Form