HOSPICE OF SWEETWATER COUNTY
VOLUNTEER APPLICATION
PLEASE PRINT 

NAME  ________________________________________________________  DATE _____________________ 
ADDRESS  _____________________________________City__________________  Zip Code______________
MAILING ADDRESS (if different) _________________________________________________________________
PHONE #(s) ________________________________________________AGE ____  DATE OF BIRTH __________ 
E-MAIL _____________________________________________________________________________________  
OCCUPATION _______________________________________  EMPLOYER _____________________________

EDUCATION   High School Attended ____________________________ Graduate? ______  Year _________ 
College Attended ______________________________ 	# years attended ___  Major _____________________

Degree: _______________________________  Other: ______________________________________________

Certification/Licensure ________________________________________________________________________

RELIGIOUS/SPIRITUAL PRACTICE (optional) _______________________________________________________
WHY ARE YOU INTERESTED IN VOLUNTEERING WITH HSC? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PREFERRED AREA (s) OF VOLUNTEER SERVICE 
_____ Patient-Family Services 						_____ Board of Directors
_____ Bereavement Services 						_____ Clergy
_____ Registered Nurse  _____ On-call					_____ Quality Assurance
_____ Other (specify) _____________________
AVAILABLE TIME TO VOLUNTEER
Weekdays ____________________________________________	Hours ___________________________
Evenings _____________________________________________	Hours ___________________________
Weekends ____________________________________________	Hours ___________________________

Revised 7/2018                                                                         

VOLUNTEER APPLICATION Continued
PLEASE ANSWER THE FOLLOWING
Do you have any health-related problems or physical limitations? _______  If yes, please describe: ________________________________________________________________________________________________________________________________________________________________________
Do you speak, understand and/or write a foreign language? ___________________________________
Are you willing to provide transportation? _____   If yes, do you have a valid driver’s license? ______
Do you have any talents which could enrich our clients (music, art, etc.)? _____ If yes, please describe:
____________________________________________________________________________________
Is there an age group you feel more comfortable with? _______________________________________
____________________________________________________________________________________
REFERENCES
1.  Name ______________________________________ Relationship __________________________
   Address ____________________________________City _______________ State ____ Zip _______
   Phone # _________________________________________________________________________

2.  Name ______________________________________ Relationship __________________________
   Address ____________________________________City _______________ State ____ Zip _______
   Phone # _________________________________________________________________________

3.  Name ______________________________________ Relationship __________________________
   Address ____________________________________City _______________ State ____ Zip _______
   Phone # _________________________________________________________________________

_______________________________________________		______________________________
Signature of Applicant						Date

Revised 7/2018