Reliance Hospice & Palliative Care | Volunteer Form
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Volunteer Form

Volunteer Application

To become a Volunteer, please fill out the form below and click on the SUBMIT at the bottom when finished.

Phone Number:

Emergency Contact

Contact Name:
Contact Phone:*
Are you 18 years of age or older?
Have you ever been convicted of a felony or misdemeanor?
If "Yes", please describe
How did you hear about Reliance Hospice's Volunteer Program?
What type of volunteer services are you interested in providing:
If "Other", please specify:
List any relevant knowledge, skills, or competencies:
Do you speak, write, or understand any foreign languages?
If "Yes", please specify:
Please describe the days and times you would like to volunteer.


High School:
Did you graduate:
Did you graduate College?
Other Training:
Did you graduate (Other Training):

WORK HISTORY - List any paid or volunteer work experience in the past 5 years, starting with your most recent employer. You may also attach an additional page or your resume.

Employer 1:
Employer 1: Start Date - End Date:
Employer 2:
Employer 2: Start Date - End Date:
Employer 3:
Employer 3: Start Date - End Date:

REFERENCES (Excluding Family Members)

Reference (1) Name:
Reference (1) Relationship:
Reference (1) Phone:
Reference (2) Name:
Reference (2) Relationship:
Reference (2) Phone:
Why do you want to be a Hospice Volunteer?
What are your thoughts and feelings about death and dying?
Have you experienced a significant loss in the past 12 months?
Have you ever been with someone at the time of death
Have you ever provided care to someone who is dying?
When thinking about your own death, what comes to mind?

Code of Ethics
As a Hospice Volunteer, I am subject to a code of ethics similar to that which binds the professionals in the field of end-of-life care. As such, I assume certain responsibilities and expect to account what is expected of me. I understand that any information that is disclosed to me while assisting the hospice is confidential. I interpret "volunteering" to mean that I have agreed to work without monetary compensation. Having been accepted as a volunteer, I expect to do my work according to the standards set forth in the Volunteer Policies and Procedures.

I hearby certify that the statements made on this application are true and accurate to the best of my knowledge. I understand that, by submitting this application, I authorize inquiries to be made concerning my employment, character, and public records for the purpose of determining my suitability as a volunteer. I affirm that I have read the Volunteer Code of Ethics and agree to abide by its regulations. I agree to respect the confidentiality of any client information I may acquire in the course of my volunteer activities.