Hospice Volunteer Application Hospice Volunteer Application Name: First Last Date: Address: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone:Cell Phone:Work Phone:Email Address:* Are you 18 years of age or older? Yes No Employer(s) (List past 3 years, Occupation/Position and Year(s))Why do you want to be a hospice volunteer?Please list any previous volunteer experiences:Talents or Hobbies:Education/training or special skills:How did you hear about Celtic Hospice?What geographic area would you like to service? Western PA North - Allegheny, Butler, Beaver Western PA South - Fayette, Washington, Westmoreland Central PA - Carlisle, Cumberland, Perry, Dauphin Northeast PA - Wilkes Barre, Scranton Missouri Illinois Any specific areas within these geograpic locations?What time schedule is best for you? Daytime Evening Weekend Do you have access to an automobile? Yes No Volunteer activities may require the use of a vehicle. A current Pennsylvania Driver's License and proof of insurance will be required.What type of volunteer service are you interested in providing? Please check your preference(s). Direct Patient Contact Administrative Tasks Bereavement Support Direct Patient Contact: This includes such activities as: companionship, socialization, running errands, light housekeeping, meal preparation, transportation, emotional support, etc.Administrative Tasks: This includes assembling mailings, writing condolence cards and special projects.Bereavement Support: This is accomplished through viewings at funeral homes and outreach to the families.Please provide two references (no relatives) that you have known at least one year.1. Name: First Last Address Street Address City ZIP / Postal Code Phone:Relationship:2. Name: First Last Address: Street Address City ZIP / Postal Code Phone:Relationship:I understand as a volunteer I will not be entitled to monetary compensation for the work I perform or be entitled to Worker's Compensation or Group Benefits in the event of an injury. As a volunteer, I realize that I am subject to a code of ethics similar to that which binds the professionals in the field in which I volunteer. I understand that any information that is disclosed to me while assisting as a Hospice Volunteer is confidential.Signature:Date: If you have any questions or needadditional information, please contact:Julie MaceikisVolunteer Coordinator for Western PAmaceikisj@healthcareathome.comDonna MillerVolunteer Coordinator for Central and North Central PAmillerd@celtichealthcare.comMarty CarrVolunteer Coordinator for Northeast PAcarrm@celtichealthcare.comLori SchmollVolunteer Coordinator for Missourischmolll@celtichealthcare.comSarah SpencerVolunteer Coordinator for Southern ILspencers@celtichealthcare.comLeslie RheineckerVolunteer Coordinator for Southern ILrheineckerl@celtichealthcare.comPlease return form by submitting button below or mail to:Hospice Volunteer ProgramCeltic Healthcare, Inc.150 Sharberry LaneMars, PA 16046FAX: 724-625-4288 This iframe contains the logic required to handle AJAX powered Gravity Forms.