Volunteer Application

FAITH HOSPICE MISSION STATEMENT

In fulfilling God's calling to serve others, we will:

Serve with love and compassion
Commit to excellence
Follow Christ's teaching and example in all we do.

* By clicking here, you are acknowledging that you can support our Mission Statement.

PERSONAL INFORMATION

* First Name

MI

* Last Name

* Preferred Name

* Home Address

* City

* State

* Zip Code

* Mobile phone

Home phone

Work phone

* E-mail address

Gender

Are you now, or have you ever been, a Holland Home/Faith Hospice Employee?

EMERGENCY CONTACT INFORMATION

* Contact name

* Relationship

Address

City

State

Zip Code

* Mobile phone

Home phone

Work phone

E-mail address

REFERENCE 1 OF 2 (no relatives - MUST provide email and/or phone)

* Name

Relationship

E-mail

* Phone

Organization

Address 1

City

State

Zip/postal

REFERENCE 2 OF 2 (no relatives - MUST provide email and/or phone)

* Name

Relationship

E-mail

* Phone

Organization

Address 1

City

State

Zip/postal

Authorization for a Criminal Background Check

An investigation consumer report consisting of a criminal conviction background check will be obtained on all new employees and volunteers of Faith Hospice. This report will be used for employment and volunteer purposes only. You have the right to make a written request within a reasonable period of time for information concerning the nature and scope of the investigation. In the event you desire this information, please contact the Volunteer Services Office. This Notice is authorized by the Fair Credit Reporting Act, Section 604(b).

I authorize Faith Hospice to conduct a criminal background check with the State Police, County Sheriff Departments, and/or a Consumer Reporting Agency for the purpose of determining my suitability for employment/volunteer work with Faith Hospice. I have listed below all crimes for which I have been convicted, including the date of such convictions, as well as any pending felony charges. I acknowledge that any omission or falsification of this form shall be grounds for discharge if I am employed or assigned as a volunteer.

* Full Legal Name

* Drivers License Number (including State)

Have you ever been convicted or plead guilty or no contest to a crime?

Do you have any felony charges pending against you?

* List of Convictions

ADDITIONAL INFORMATION

* How did you hear about us?

Skills you are willing to share

Can you commit to at least one year of volunteering?

* If not, please explain

How frequently can you volunteer:

I Prefer a Flexible Schedule

I Prefer a Regular Schedule

Weekly - once or twice a week

Monthly - two or three times a month

On Call or As Needed

Weekdays - Mornings

Weekdays - Afternoons

Weekdays - Evenings

Saturdays

Sundays

Are you at least 18 years of age?

You must be at least 18 years of age in order to volunteer.

Military Experience

Communication Language

Additional languages

I am a student.

I attend school/college:

I am employed.

I work at (employer):

* Reason for wanting to volunteer or what you hope to do as a volunteer?

Attestation of Application Answers and Information Provided

I hereby represent that the above information is true and complete. I have not withheld anything from this application which, if disclosed, would affect this application unfavorably. I understand that if Faith Hospice should determine at any time that any of the requested information was withheld by me, or that any of the statements given in this application were false or misleading, I may be refused the opportunity to volunteer, or, if currently volunteering, would be discharged immediately. I understand that I will be free to leave my volunteer position at any time with or without cause; and I understand and agree that Faith Hospice also may terminate my volunteer duties at any time with or without cause.

If I become a Faith Hospice volunteer, I will comply with all rules, regulations, policies and communications directed to volunteers. I hereby authorize Faith Hospice to conduct a routine criminal history check (if I am 18 or older), and thoroughly investigate my work, medical and personal history that is job-related. I also authorize Faith Hospice to communicate with the references I provided above. If arrested or convicted for any of the following criminal offenses-abuse, neglect, assault, battery, theft, fraud, criminal sexual conduct, or any felony-I agree to immediately report it to the Volunteer Services Department.

I understand that I may not be selected as a volunteer for any reason, and that if I become a volunteer, my status as such may be terminated at any time for any reason.

* I AGREE

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Upload Add'l File

Full Legal Name (e-signature)

* Type Full Legal Name (e-signature)