Hospice of Central New York

Volunteer Application Form

Hospice of Central New York does not discriminate on the basis of race, ethnicity, color, sexual orientation or religion.

Thank you for your interest in becoming a Hospice of CNY volunteer. This application form was developed specifically for the Hospice program and is confidential. The information will help us to find the kind of work assignment you will most enjoy.

Name:______Date: ______

Address:______Phone: ______

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Email:______FAX: ______

Occupation:______

Employer:______Business Phone: ______

Education/Schools AttendedDegreeMajor

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How did you learn about Hospice volunteer opportunities? ______

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Employment HistoryDateDescription of Work

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Professional Affiliations/Honors: ______

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Volunteer ExperienceDateDescription of Work

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— Over —

Are you a Veteran?: ______

Experience, special skills, office skills, arts and crafts, music, etc: ______

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Foreign languages: ______

Have you ever been convicted of a crime or violation other than minor traffic infractions?

(Conviction would not necessarily result in the denial of role of Family Care Giver)

If yes – please explain ______

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Has someone close to you died recently? If yes, please explain the impact on you:

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Who should we contact in the event of a volunteer accident or illness?

Name: ______Phone: ______

Any other remarks? ______

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As a volunteer, I realize that I am subject to a code of ethics similar to that which binds paid employees of Hospice of CNY. I, like them, assume certain responsibilities and expect to account for what I do in terms of what is expected of me.

I interpret “volunteer” to mean that I have agreed to work without compensation in

money but having been accepted as a volunteer worker, I expect to do my work according to standards set forth in the Volunteer Policies and Procedures Manual.

By my signature, I declare that the above information is true and correct as contained in this application.

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Volunteer’s Signature Date Interviewer’s Signature Date

Hospice of Central New York complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Hospice of Central New York cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-315-634-1100.

Hospice of Central New York 遵守適用的聯邦民權法律規定，不因種族、膚色、民族血統、年齡、殘障或性別而歧視任何人。

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電1-315-634-1100.

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