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Hospice and Palliative Care Volunteer Application

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Hospice and Palliative Care Volunteer Application

List last or current employment experience:
Please complete this application form if you are interested in becoming a Hospice & Palliative Care volunteer for Evergreen Hospital Medical Center. Please provide two personal references (1,2). When we receive your references, we will contact you for a personal interview. When you complete the form, please click the submit button at the bottom.
* Indicates required information
Prefix: *	Mr. Mrs. Ms. Miss
Last Name *
First Name *
Middle
Address *
City *
State *
Zip Code *
Email: *
Home Phone: *
	Okay to call me here
Cell Phone: *
	Okay to call me here
Work Phone *
	Okay to call me here
Are you at least 18 years of age? *	Yes No
Date of Birth *	(mm/dd/yyyy)
Organization: *
Title: *
Type of work: *
Dates: *
Describe previous volunteer/internship experiences, including hospice:
Organization:
Duties:
Dates:
Organization:
Duties:
Dates:
Organization:
Duties:
Dates:
Reference #1
First name: *
Last name: *
Street: *
City: *
State: *
Zip: *
Home phone: *
Cell phone: *
Email address: *
Relationship *
Reference #2
First name: *
Last name: *
Street: *
City: *
State:
Zip: *
Home phone: *
Cell phone: *
Email address: *
Relationship *
How did you hear about our program? *	Evergreen Hospital Website Personal experience with Hospice United Way Website Attended a Presentation VolunteerMatch Website Newspaper Ad or article Our bookmark Other website Friend or Relative Other If Other, please specify:
What volunteer opportunity are you most interested in? *	Animal Assisted Therapy Patient & family support in patients' places of residence Hospice Center Compassionate Touch Office support
Personal Loss
Have you had a personal involvement with a death or a life threatening illness of someone close to you? *	Yes No
What was the person's relationship to you? *
What was the date of the death? *	(mm/dd/yyyy)
Bereavement
Have you participated in bereavement follow-up or counseling for yourself? *	Yes No
Why are you interested in hospice?
Why are you interested in working with dying patients and their families? *
What do you feel your strengths would be in working with patients and families? *
What do you feel your weaknesses would be in working with patients and families? *
Your experiences with loss and stress
Have you experienced a stressful circumstance in the last year? If yes, please explain. *
What support system do you have for yourself when you experience a loss? *
Are you in active treatment for a potentially life-threatening illness? *	Yes No
Your volunteer experience
What do you hope to gain from your volunteer experience? *
I affirm that all information on this form is true
*	I understand and consent to the background check for criminal history through the Washington State Patrol as required by law. I affirm that all information on this form is true.

Please copy and paste this link in an email to your two references so they can send the reference form back to us. We must receive two references before you can go forward with the application process. http://www.evergreenhospital.org/body.cfm?id=1701

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