* Indicates required field. We appreciate your interest in volunteering for Good Samaritan Hospice. We are committed to making your experience rewarding and beneficial to the community that we serve. The information in this application will enable us to create the most appropriate volunteer assignment possible.

GENERAL INFORMATION

Date of application: (mm/dd/yyyy) Email address:*

First name:* Last name:* Date of birth:* (mm/dd/yyyy)

Street address:*

City:* State:* ZIP code:*

Home phone:* Work phone: Mobile Phone:

AVAILABILITY

May we contact you at work? YES NO Hours that you work:

Enter the total number of days and hours per week you could be available for hospice volunteering. How many days per week? Week days: (hours) Week evenings: (hours) Weekends: (hours)

Which day(s) would you be available?

EMPLOYMENT

Please list your employer(s) for the past five years. From: (mm/yyyy) To: (mm/yyyy) Employer: Occupation/Position: From: (mm/yyyy) To: (mm/yyyy) Employer: Occupation/Position: From: (mm/yyyy) To: (mm/yyyy) Employer: Occupation/Position:

EDUCATION / SPECIAL TRAINING / LIFE SKILLS / WORK EXPERIENCE

List those items that you believe could be helpful to you in your hospice work. (ie. office skills, special trainings, art, etc.) From: (mm/yyyy) To: (mm/yyyy) Education/Experience: From: (mm/yyyy) To: (mm/yyyy) Education/Experience: From: (mm/yyyy) To: (mm/yyyy) Education/Experience:

PERSONAL INFORMATION

Have you ever done any volunteer work? How did you hear about Good Samaritan Hospice? Why do you wish to be involved in hospice work? Will you be able to work with someone of a different religious faith than you? YES NO Will you be able to work with someone who practices a different lifestyle than you? YES NO Are you willing to provide transportation for patient/family if needed? YES NO Are there any special circumstances relating to your health that we should consider when assigning you? YES NO If YES, please explain: Has someone close to you died? YES NO If YES, when did this occur? (mm/dd/yyyy) Explain how this person's death effected you?

VOLUNTEER OPPORTUNITIES

Good Samaritan Hospice offers many opportunties to volunteer team members. Please indicate all areas in which you are interested. Patient Care (in patient homes) Bereavement Visitation Clerical Patient Care (in Good Samaritan House) Bereavement Telephone Contact Fund Raising Patient Care (in Concordia Inpatient Unit) Bereavement Mailings Public Relations Professional Consultation (specify are of expertise): Other, please specify:

REFERENCES

Please list three personal references (no relatives) whom you have known for at least one year. Name: Address: Phone: Name: Address: Phone: Name: Address: Phone:

For assistance completing this form, please call 1-800-720-2557 and a Good Samaritan representative will be happy to help you.

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