Volunteer Application

*Indicate required fields
*First Name		Note: If you are having problems submitting the application form you may fill out and send in the hard copy form by clicking here.
*Last Name
*Address
*City
*State
*Zip
*Home Phone	(include area code)
Work Phone	(include area code)
*Email

Are you 18 years of age or older?	Yes No
*Education

Degrees Earned

Occupation

*Present/Previous Employment

Present Volunteer Service

Past Volunteer Experience

Special Skills or Training
Do you have reliable transportation?	Yes No
If interested in position that involves driving, do you have a valid drivers license and insurance?	Yes No
DL#
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

Working with Music Therapy

Group facilitation or Support contact

Other

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


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, ST Zip
*Phone
*Name Two
Address
City, ST Zip
*Phone
*Name Three
Address
City, ST Zip
*Phone

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269-345-0273 - Fax 269-345-8522