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Volunteer Application

Please be prepared to complete this application in one sitting. If you do not think you will be able to complete the form at one time, you can download the pdf version (from the Volunteer page) and submit via facsimile. Thank you.

* Required fields

Please Select Your Volunteer Interests: Office Work PR/Outreach Patient Care Camps Auxiliary Treasures (resale shop) Special Events Other/Not Sure
Name *
Street Address
City
State
Zip Code
Home Phone Number *
Work Phone Number
Cell Phone Number
Email Address *
Name of person to be contacted in an emergency: *
Phone number of person to be contacted in an emergency: *
Are you (response optional): Male Female
Are you (response optional): African American American Indian Asian Hispanic Caucasian Other
How did you about Hospice of the Chesapeake volunteer opportunities (specify answers below)? Friend/Relative Newspaper Church Community Event Internet Personal Experience Hospice Employee Hospice Volunteer Hospice Presentation The Life Center Other
Please use this space to specify your previous answer:
Please list formal education (school, diploma/degree and course/major):
Please list your last three jobs (company, description of work and dates):
Please list any volunteer experience you have (organization, description of work, dates):
Please describe any volunteer training you have had:
What day(s) and time(s) would you be available to volunteer?
Why do you want to be a Hospice of the Chesapeake volunteer?
How would you describe your health in the past year? Excellent Good Fair Poor
Do you have any physical or emotional restrictions which might affect your volunteer placement with hospice? If so, explain:
Have you experienced the death of a loved one in the past year?
Do you have a valid drivers license?
Do you have access to a car?
Are you afraid of and/or allergic to dogs, cats or smoke?
What special skills do you have (specify below)? Clerical Practical Visual Arts/Crafts Music Language Community Outreach Special Events Other
Please use this area to specify your special skills noted above:
Please list the full name, phone number, occupation, address and relationship to you for 3 references:
captcha *
By clicking the submit button you agree to make a minimum one year commitment as an active volunteer with Hospice of the Chesapeake.
Anne Arundel County
445 Defense Highway
Annapolis, MD 21401
phone: 410.987.2003
Prince George's County
8724 Jericho City Drive
Landover, MD 20785
phone: 301.499.4500


 

 



 

The public may contact the Joint Commission's Office of Quality Management to report any concerns or register complaints about a Joint Commission-accredited health care organization by either calling 1(800) 994-6610 or emailing complaint@jcaho.org.

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