VA Volunteer Form

Name

Address

Phone

Email

Birthdate MMDDYYYY

Emergency Contact

Emergency Contact Phone

Are you currently employed?

Yes‎ No‎

If so.....

Full Time‎ Part Time‎

Place of Employment:

Available Times

AM‎ PM‎

Do you have transportation readily available?

Yes‎ No‎

Are you willing to travel to nearby cities or rural areas?

Yes‎ No‎

Are you currently attending school?

Yes (Part Time)‎ Yes (Full Time)‎ No‎

Name of School & Course of Study?

Do you have any physical limitations? If yes, please explain:

Please list any organizations you belong to:

Please list any skills, interests, or hobbies you feel may be utilized in your volunteer work:

Please share your reason(s) for wanting to work with Personal Touch Hospice:

How did you hear about the Personal Touch Hospice Volunteer Program?

Have you experienced a personal loss within the past year?

Digital signature

Clear

Terms

By signing your name above, you agree to the following statement: I certify that the information contained in this application for a volunteer position is correct and complete. I understand that false statements, answers or omissions on this application shall disqualify me from consideration for a volunteer position, or dismissal after placement. I authorize Personal Touch Hospice to investigate any or all information on this application concerning my previous employment, education, institutions and police agencies from all liability for any damages in furnishing information. My volunteer placement will be based on the receipt of satisfactory information and on my ability to perform the essential functions of the volunteer position for which I have applied.