Penn Medicine Hospice Princeton Volunteer Application

Demographic Information

* First name

* Last name

* Date of Birth

Gender

Please use the box below if you sleected 'prefer to self describe'

* Street Address

Apartment, etc.

* City

State

* Zip Code

Phone (home)

* Phone (cell)

* Name of Employer (if retired, former)

Phone (business)

May we call you at this number?

Work Position

Highest level of education completed

Would you be using your car to travel to and from assignments?

Military Affiliation (OPTIONAL)

Please indicate any military affiliation you may have.

Please indicate which branch of the military you are affiliated with.

Emergency Contact

* Contact name

Relationship

* Emergency Contact phone (mobile)

Volunteering Background

Skills

Additional languages

Previous volunteer experience

My interests and hobbies include:

Hospice Specific Questions

How did you hear of Penn Medicine Hospice?

If you replied 'other' please give specifics:

If you were referred by another volunteer, please enter the volunteer's name.

Have you had Previous Hospice training?

(If yes, please indicate name of Hospice & year completed)

Reason for VolunteeringBriefly describe your interest in becoming a Hospice Volunteer:

* Loss History

Availability

Please indicate which time frames you may be available. Assignment hours are not

restricted to the timeframes below.

Sunday

8am-Noon

Noon-5pm

5pm-9pm

Monday

8am-Noon

Noon-5pm

5pm-9pm

Tuesday

8am-Noon

Noon-5pm

5pm-9pm

Wednesday

8am-Noon

Noon-5pm

5pm-9pm

Thursday

8am-Noon

Noon-5pm

5pm-9pm

Friday

8am-Noon

Noon-5pm

5pm-9pm

Saturday

8am-Noon

Noon-5pm

5pm-9pm

Volunteer Roles

Penn Medicine Hospice also asks that volunteers comply with the following requirements:

Provide a TB Blood Test
Provide proof of Covid Vaccination
Annual Flu Shot (Required of all volunteers working in the office, or having direct patient contact November 1 through March 31).
Allow us to complete a Background Check.
Provide 2 letters of recommendation.
Copy of Driver's License or Photo ID (when it expires, it must be updated)
Copy of Auto Insurance-only necessary for those using a car to volunteer (when it expires, it must be updated)

I certify that the statements made on this application for a Hospice Volunteer position are true and correct, and I hereby grant Penn Medicine Hospice permission to verify the information contained herein. I understand the giving of false information or the failure to give complete information requested herein shall constitute grounds for rejection of my application or my dismissal from the program. I understand that my appointment with Penn Medicine Hospice is contingent upon the satisfactory completion of the required orientation and training, and the receipt of satisfactory recommendations from references. I also understand that Penn Medicine Hospice reserves the right to require tests for drugs and/or alcohol in my system for just cause or reasonable suspicion. I hereby grant permission for the authorities of Penn Medicine Hospice to investigate my references and release Penn Medicine Hospice and all previous employers or references from any and all liability resulting from such investigation. Upon becoming inactive as a Penn Medicine Hospice Volunteer, I authorize the release of reference information on my work.

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Signature (required)

* Application date