Volunteer Application

Join Us!

Personal Information

First Name *
Last Name *
Middle Initial
Street Address *
City *
State *
Zip Code *
Home Phone
Cell Phone *
Work Phone
Email Address *
Do you have a loved one in hospice care at this time?
Yes      No

Have you experienced the death of a significant loved one within the past year?

*We ask that applicants desiring to volunteer directly with patients wait 9 months after the death of a loved one to begin the process of becoming a volunteer.

Yes      No

Emergency Contact Information

Name *
Relationship
Home Phone
Cell Phone *
Work Phone
Email Address *
Family Physician

Volunteer History

Organization
From (Mo/Yr)
To (Mo/Yr)
Position/Description of Role
+ Add Volunteer Experience

Employment Experience

Name of Employer
From (Mo/Yr)
To (Mo/Yr)
Position/Description of Role
+ Add Employment Experience

References

Name *
Relationship*
Email *
Phone *

Name *
Relationship *
Email *
Phone *

Record Checks

Due to the serious nature of the work done by HPCCR and the responsibility placed upon volunteers, it is our practice to conduct criminal history background checks (CHBC) before accepting an individual into the volunteer program.
Have you ever been convicted of a criminal offense?
Yes      No

Areas of Service

Patient/Family Support
Levine Dickson Hospice House-Huntersville
Levine Dickson Hospice House at Southminster
Staff Support
Group Opportunities
Special Skills
Specify

Skills and Abilities

Please identify all skills and abilities that apply. Also note any special skills and knowledge that might be pertinent for the volunteer position desired.

Computer Skills (check all that apply)
Word
Power Point
Publishing Software
Excel
Website Design
Video-audio
Outlook
Graphics Software
Database Management
Any additional computer knowledge/skills:
Additional Skills and Talents (i.e., multi-lingual, theatrical skills, photography, artistic ability, hobbies/crafts, etc.)

Questionnaire

1. How did you hear about our volunteer opportunities? *
2. Why do you want to become a volunteer with our organization? *
3. What values can you bring to our organization? *
4. If you were told you only had six month to live, what would you do? *
5. What are your experiences with and/or personal philosophy on death/grief? *
6. In which geographic areas (zip codes) are you willing to volunteer? *
By checking this box, I certify that this is my electronic signature and that I am authorized to submit this information.
Submit

At times, information concerning a volunteer may be used in a press release, for fundraising purposes or other reasons deemed appropriate by HPCCR.  By submitting this application, the volunteer provides consent for HPCCR to use the volunteer’s name, title, portrait, picture, video image, photograph, or any reproduction likeness or quotation of the  volunteer’s remarks for public information, fund-raising purposes, or other organization programs as approved by HPCCR.

HPCCR is not obligated to provide a placement, nor are you obligated to accept a position offered. Opportunities for volunteers are provided without regard to race, religion, gender, ethnic origin, disability, age, or sexual orientation.

I understand that all volunteers represent HPCCR and are subject to the rules, and regulations of the organization.  I authorize the organization to acquire additional information from references included in this application, and I hereby release them, their companies and HPCCR from any liability whatsoever concerning information obtained through this application.

HPCCR Volunteers are expected and required to report on time for accepted assignments and in appropriate mental and physical condition for work. It is our intent to provide a healthful, safe, and secure work environment. However, as a volunteer with Hospice & Palliative Care Charlotte Region (HPCCR), I understand that I am volunteering at my own risk whether at an HPCCR facility, third party facility, special event, patient homes, or while commuting. I understand that HPCCR is not liable for any claim that I may have with respect to any bodily injury, personal injury, illness, death, or property damage that may result from volunteer activities whether caused by the negligence of HPCCR or its board of directors, employees, agents or otherwise. I also understand that HPCCR does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health, or disability insurance in the event of injury or illness.

The information provided has been completed thoroughly and truthfully by the Volunteer Program applicant. This application and any other documents obtained during the application process will remain confidential in the HPCCR  Volunteer Services Office.

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