VOLUNTEER APPLICATION

 

Name *
Name
Address *
Address
Home Phone
Home Phone
Mobile Phone
Mobile Phone
Date of Birth *
Date of Birth
Can you speak, read and write that language?
Check all that apply
Explain
Home Phone
Home Phone
Work Phone
Work Phone
Mobile Phone
Mobile Phone
Please provide the names of two professional or personal references who are not related to you.
Phone *
Phone
Phone *
Phone
Listed below are some of the activities Kare-In-Home Volunteers can be of assistance *
Please check all that you are interested in.
At times, information concerning a volunteer may be used in a press release or other reasons deemed appropriate by Kare-InHome Hospice. Submission of this application provides consent for Kare-In-Home Hospice to use the volunteer’s name, title, portrait, picture, video image, photograph, or any reproduction likeness or quotation of the volunteer’s remarks for public information or other organizational programs. If you accept, select "yes."
Please read the following statements with your teen volunteer applicant and sign below: Teens under 18 years old are not allowed to transport patients or their family members by auto. Universal Precautions taken by medical personnel when working with all patients and Infection Control are taught during volunteer training. All patient information is confidential. Since your child may share information with you concerning their volunteer experience, your signature below indicates that you will keep in confidence any information shared with you about a Kare-In-Home Hospice patient. All teen volunteers must document each visit with patient/family. This documentation becomes part of the medical record which is an integral part of the Kare-In-Home Hospice plan of care for the patient and facilitates government funding. If you accept, select "yes," and provide your printed signature below.
Parent/Guardian Name (Print Signature): *
Parent/Guardian Name (Print Signature):
Date *
Date
All new volunteers with Kare-In-Home Hospice must be administered two TB tests prior to working with patients. These tests are available at no charge. The first test is administered during volunteer training with results evaluated on the second day following the test. The second test is administered two weeks after the first. Your signature below authorizes Kare-In-Home Hospice to administer the required TB Screening for your teen. Kare-In-Home Hospice has my permission to administer required TB Screening for my child. If you accept, select "yes," and provide your printed signature below.
Date *
Date
I certify that all information I have provided is true, complete and correct and understand this application and any other documents obtained through the application process will remain confidential in the Kare-In-Home Hospice Volunteer Services Office. I expressly authorize, without reservation, Kare-In-Home Hospice, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and education institutions and to otherwise verify the accuracy of all information provided by me in the application. I hereby waive any and all rights and claims I may have regarding Kare-In-Home Hospice, its agents, employees and representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the volunteer process and all other persons, corporations or organizations for furnishing such information about me. I understand that Kare-In-Home Hospice does not lawfully discriminate and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for volunteering on any basis prohibited by applicable local, state or federal law. I understand that all volunteers represent Kare-In-Home Hospice and are subject to the rules and regulations of the organization, including volunteer training, background checks, fingerprinting, Tuberculosis (TB) testing and a health screening, and that at any time I may be subject to random drug testing. I also understand I will be required to provide proof of identity. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for volunteering or (ii) may result in my immediate discharge from Kare-In-Home Hospice, whenever it is discovered.
Signature Confirmation of above Signatures & Authorization Statement *
Signature Confirmation of above Signatures & Authorization Statement
Do not sign until you have read the above statement. I certify that I have read, fully understand and accept all terms of the foregoing application statement.
Date *
Date