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* 1. Volunteer Name:

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* 2. Preferred name

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* 3. Date:

Date

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* 4. Full Address including City, State, Zip

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* 5. Email Address:

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* 6. Phone:

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* 7. Present employment:

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* 8. Are you a current Hospice of Spokane employee?

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* 9. Are you a past employee or volunteer of Hospice of Spokane?

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* 10. Are you related to any current Hospice of Spokane employee?

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* 11. Are you required to volunteer?

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* 12. Volunteer Experience.

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* 13. Special talents/skills:

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* 14. Relevant education or training:

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* 15. When working with dying and grieving people, we often find that our own experiences in facing loss provide some of our strongest learning. Please list persons close to you who have died, the cause of death, and their relationship to you:

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* 16. What things were helpful to you during the grieving process?

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* 17. Were there some things that people said or did that were not helpful?

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* 18. Is there any group of people you feel especially suited to work with? Do you feel that your experience makes you better-suited to support patients suffering from a particular illness?

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* 19. What do you hope to gain by working with Hospice of Spokane?

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* 20. Is there anything in your medical history that should be considered in utilizing you as a volunteer?

Medicare requires the following from volunteers & employees: 
   * Initial 2-part TB skin test (provided during volunteer training by Hospice of Spokane)
   * Washington State Criminal Background Check (provided by Hospice of Spokane
Hospice of Spokane’s insurance provider requires all volunteers & employees have a good driving record and proof of current auto insurance.  Hospice of Spokane will check driving records and request proof of current auto insurance and state driver’s license or official photo identification.

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* 21. Our goal at Hospice of Spokane is to employ volunteers in a way that is fulfilling to them and best meets the needs of our clients. Here are some of the ways your talents and interests may be utilized at Hospice of Spokane. Please feel free to add other ways you envision yourself volunteering.

Check those areas of service below that you would strongly consider doing as a hospice volunteer. We will further discuss these options during and after training.

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* 22. Veteran/Active duty Branch of Service:

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* 23. Please list three (3) character references(Only one reference can be a family member.)
Reference 1:

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* 24. Contact by:

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* 25. Reference 2:

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* 26. Contact by:

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* 27. Reference 3:

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* 28. Contact by:

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* 29. Disclosure Statement:
Your activities may include unsupervised access to children, vulnerable adults and developmentally disabled individuals. Washington state law requires that we obtain a Washington State patrol background check. Your role/ position will be conditioned upon the receipt of a satisfactory report.
Pursuant to RCW 9A.72.085, I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. I understand that I can be discharged for any misrepresentation or omission in the above statement.