VOLUNTEER APPLICATION					
Please print clear and complete all items.			
Last Name  	First Name                                                         	Middle Name	
Present Street Address	City, State Zip Code	County                                                               	Email	
Home Phone Number	Cell Phone or Pager Number   .	Date of Birth 	
Emergency Contact Name	Phone		
Have you ever been convicted of a crime?  __ Yes  __ No
(If yes, please provide date(s) and details.)	Answering 'YES' to this question does not necessarily disqualify you from volunteering. Factors, such as date of the offense, seriousness of violation, and position applied for will be taken into account	
VOLUNTEER SERVICE DESIRED

Areas of Interest: ____ Patient/Family Care  ____ Bereavement     ____Office Work    _____Speakers' Bureau     ____Bake & Take Team     ____Publicity ____Special/HoIiday Projects   ____ Telephone Calls  ____Milo’s Friends Pet Program      _____Woodworking   _____Yard Work      ____Gardening  ____Housekeeping   _____Foreign Language   ____Sign Language      Other _________________________________________________

I am a licensed:  __PT      __OT       __Beautician/Barber __Manicurist      __Massage Therapist
List any special interests or hobbies.:    ____________________________________________________________
List the hours that you are available for volunteer service: 
Morning: ______  Afternoon:  ________   Weekend:_______ Evening: _______ Night: _______

How did you hear about the Hospice program? ____________________________________________________________________________
_________________________________________________________________________________________________________________
Why do you want to be a Hospice volunteer? _____________________________________________________________________________
_________________________________________________________________________________________________________________

Name and Location of Last School Attended/Attending: _____________________________________________________________________________________
City:_____________________State: ______________________

Degree/Area of Study:
Graduated __Yes    __No
list any skills, courses or training applicable to the volunteer service applied for.
_________________________________________________________________________________________________________________________
Are you presently employed?  ___Yes  _____No            If yes, plase list place of employment _________________________________________

	

PERSONAL REFERENCES	
List three persons who know you well are not related to you and are not your previous supervisors.	
Name	Phone Number 	Relationship to You	# of Yrs. Known	

				

All applicants are subject to a PPD Test, Drug Test and SLED Criminal Background Check
Today's Date_________________

Applicant Signature __________________________________________________

Parent Signature (if under 18)  __________________________________________

WE APPRECIATE YOUR INTEREST IN VOLUNTEERING FOR HOSPICE CARE OF SOUTH CAROLINA