Hospice Application revised 11/09/18

Personal Information

What site are you interested in volunteering at?

Are you 18 years or older?

* First Name

* MI

* Last Name

Preferred Name

* Home Address

* City

State (as combo)

* Zip Code

* Preferred phone

Type

* Mobile phone

Home phone

* E-mail address

Contact flags

What is your Gender?

Emergency Contact Information

* Contact name

* Relationship

Line 1

City/State/Postal

* Preferred phone

Mobile phone

Home phone

E-mail

Additional Information

* How did you hear about us?

Are/were you or a family member an employee or volunteer of HFHS?

If you or a family member were or are an employee or volunteer of HFHS, please explain here

Volunteer Preferences

Skills (What skills would you like to utilize in a volunteer role)?

Volunteer Placement Preferences

If other, please indicate interest(s) here

What are your physical and social preferences for a volunteer role?

Experience & Education

I attend school/college:

I am employed.

I work at (employer):

I have military experience.

If so, please explain:

What primary language do you speak?

Additional languages

Reference 1 of 2

* Name

Relationship

Phone

E-mail

Organization

Address 1

City

State

Zip/postal

Reference 2 of 2

* Name

Relationship

Phone

E-mail

Organization

Address 1

City

State

Zip/postal

Volunteer Questions & Other Info

* What abilities or strengths do you have that would be helpful as a hospice volunteer?

* Why do you want to be a hospice volunteer?

Have you had someone close to you die within the last 12 months?

Do you agree to be tested for TB and have a seasonal flu vaccine if needed

* I certify that responses on my online application are true to the best of my knowledge. I agree that this information may be verified and references contacted by Henry Ford Hospice. Misrepresentation of facts constitutes cause for separation from Volunteer Services. (Please electronically sign below)

VSys Hospice Application revised 11/09/18