Home Care / Hospice Care / Hospice Care Volunteer Form

Hospice Care Volunteer Form

place field "FirstName" below

To protect the safety and security of those we serve UR Medicine Home Care will conduct reference and background checks for all potential volunteers. Your signature on the Authorization of Disclosure form authorizes UR Medicine Home Care to conduct a background check to obtain information through criminal record inquiries, public records, and driving record.

If you would like to volunteer at one of the hospice locations UR Medicine Home Care services, please fill out the form below.

Your Information

First Name*

place field "MiddleInitial" below

Middle Initial

place field "LastName" below

Last Name*

place field "Email" below

Email Address*

place field "Phone" below

Phone Number*

place field "StreetAddress" below

Street Address*

place field "City" below

City*

place field "State" below

State*

place field "ZipCode" below

Zip Code*

place field "Employer" below

Employment Information

Employer

place field "Occupation" below

Current or Retired Occupation*

place field "EmployersAddress" below

Employer's Address

place field "EmployersCity" below

City

place field "EmployersState" below

State

place field "EmployersZip" below

Zip Code

place field "ContactedWork" below

Can you be contacted at work?

Yes No

place field "EducationCompleted" below

Education and Interests Information

Education completed

place field "Languages" below

Know any languages other than English?

Yes No

place field "Languagesknown" below

If yes, which languages?

place field "Educationother" below

Other Education or Enrichment

place field "SpecialTraining" below

Special Training, Hobbies or Office Skills

place field "EmergencyContactName" below

Emergency Contact Information

Name*

place field "EmergencyContactPhone" below

Phone*

place field "EmergencyContactEmail" below

Email

place field "EmergencyAddress" below

Street Address*

place field "EmergencyCity" below $$validation:EmergencyAddress1$$

City*

place field "EmergencyState" below

State*

place field "EmergencyZip" below

Zip Code*

place field "ReferenceName1" below

Personal References

Please provide a completed address, as references are verified by mail. Please exclude family members.

First Reference

Reference Name*

place field "ReferencePhone1" below

Phone*

place field "ReferenceEmail1" below

Email

place field "ReferenceAddress1" below

Street Address*

place field "ReferenceCity1" below

City*

place field "ReferenceState1" below

State*

place field "ReferenceZip1" below

Zip Code*

place field "ReferenceName2" below

Second Reference

Reference Name*

place field "ReferencePhone2" below

Phone*

place field "ReferenceEmail2" below

Email

place field "ReferenceAddress2" below

Street Address*

place field "ReferenceCity2" below

City*

place field "ReferenceState2" below

State*

place field "ReferenceZip2" below

Zip Code*

place field "PatientFamilyCare" below

Areas of Interest

Patient or Family Care

In-home Nursing Home Hospital Transportation Errands Respite Friendly Visit Bedside Choir Bereavement

place field "Nonpatient" below

Non-Patient Services

Clerical Fundraising Mailings Special Events

place field "Other" below

Other skills or services

place field "AccessTransportation" below

Do you have access to transportation?

Yes No

place field "Dying" below

Have you ever provided care to someone who was dying?

Yes No

place field "HearAbout" below

How did you hear about our Hospice volunteer program?

place field "Why" below

Why do you want to be a Hospice volunteer?

place field "Qualities" below

What qualities (skills, knowledge, talents, or life experiences) do you feel you can incorporate into your hospice volunteer work?

place field "Fear" below

Do you have any fears or concerns about volunteering for people with a terminal illness?

place field "PhysicalLimitations" below

Do you have any physical limitations or health problems which may restrict your volunteer activities?