Volunteer Application

Thank you for you interest in becoming a Beacon Hospice Volunteer. Please complete the following application. All information will be held strictly confidential.

Personal Information
First Name: *   M.I.:
Last Name: *
Address: *   Apt.:
City: *
State: *     Zip Code: * 
Home Phone: *
Alternate Phone:
Email: *
This information is optional and is for informational purposes only:
Are you older the age of 18?: Yes   No Gender: Male   Female
Education Level: High School
Doctorate
Associate
Trade
Bachelor
Other
Master
 
Ethnicity: African American
Native American
Caucasian
Other
Asian
 
Hispanic
 
Job Information
Are you Employed? Yes    No      Hours Worked
Job Title:
Work Location:
Emergency Contact Information
First Name:   M.I.:
Last Name:
Address:   Apt.:
City:
State:     Zip Code:
Home Phone:
Alternate Phone:
Email:
Relationship:
Volunteer Information
Have you ever done volunteer work? Yes    No
(If yes, please explain)
Have you had any experience with end-of-life care?  Yes    No
(If yes, please explain)
Have you experienced a significant loss in your life within the last two years (i.e. death, divorce, job loss, other?)  Yes    No  
(If yes, please explain how you think this would/would not impact your work as a hospice volunteer)
Have you had any study or training in the area of grief and/or loss? Yes    No
(If yes, please explain)
Do you belong to any clubs and/or organizations?  Please list:
What do you believe you can bring to the patients and families you may visit?
Volunteer Areas of Interest  (Please check all that apply)
Direct Patient Care – Provide support and companionship to patients and families
Phone Support – Provide weekend support phone calls to patients and families
Sitting Vigil Volunteer – Spend time with patients as they are actively dying
Complementary Therapy Volunteer – Provide healing therapies (reiki, massage, etc.) to patients. 
      (Must provide proof of licensure and/or training.)
Spiritual Support Volunteer – Assist with spiritual needs such as praying, saying the rosary, etc 
      (These services provided ONLY at the REQUEST of the PATIENT)
Family Support Volunteer – Provide respite care to patients/families
Language Skills (Please enter languages spoken and indicate level of ability)
Speak Read Write
Speak Read Write
Speak Read Write
Speak Read Write
Additional Information
Do you drive?  Yes    No     Do you have access to a vehicle? Yes    No 
 
Please tell us anything else you would like us to know:
I hereby request Beacon Hospice to process my application to become a volunteer.  I have completed the application to the best of my ability and state that all information that I have provided is true and accurate to the best of my knowledge.