CONTACT INFORMATION

Name

First Name

Last Name

Email Address

Enter your best email so we can stay in touch!

Phone Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

VOLUNTEER DEMOGRAPHICS

Date of Birth

Gender

Education

Are you currently a student?

Yes

If yes to the previous question, please list the name of your school.

Are you a Veteran?

Yes

Are you currently employed?

Yes

What's your occupation?

Employer Name

If applicable, list your employer's name below.

List your current or most recent employer.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you ever been employed by Absolute Hospice?

INTERESTS & AVAILABILITY

What Area Would You Like to Serve?

Canton/North Canton (and surrounding areas)

Akron (and surrounding areas)

Greater Cleveland (and surrounding areas)

Caldwell (and surrounding areas)

Pickerington (and surrounding areas)

Volunteer Positions

Check all the positions that you're interested in.

Patient/Family

Bereavement

Pet Therapy

Crafting

Spiritual Support

Please share why you're interested in volunteering with Absolute Hospice.

We value your "why". Please share why you want hospice volunteering to be a part of your life.

Have you experienced loss in your life?

Share how loss will lend to volunteer experience.

If your loss is recent, we encourage you to take a period of 12 months to process through your grief prior to becoming a volunteer. If you need assistance, we can help. Contact our Bereavement Coordinator at 330.498.8075, Thank you.

Let us know if your loss is recent, below.

Availability

Please check all that apply to you and your schedule.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

What time of day works best for you and your schedule?

Please check all that apply to your and your schedule.

Morning

Afternoon

Evening

Flexible

REFERENCES

References offer us valuable insight into who you are. Please provide two that can attest to your commitment and character.

Reference 1

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Relationship

Reference 2

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Relationship

DISCLOSURES

Have you ever been arrested for, convicted of or pled no contest to a crime (other than minor offenses such as traffic tickets)?

Yes

If yes to the previous question, please explain.

Do you use any chemical substances, to include illegal drugs that would in any way impair or limit your ability to perform the functions of your job with reasonable skill or safety?

Yes

If yes to the previous question, please explain.

EMERGENCY CONTACT

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Relationship

Where did you learn about this volunteer opportunity?

Letting us know where you heard about us, improves our marketing efforts.

SIGNATURE & ACKNOWLEDGEMENT

The information that I have provided on this application is accurate and true to the best of my knowledge. The persons, current and prior employers (if approved by me in the Employment History section) and other organizations or employers named in this application are authorized by me to verify the information I have provided. I am willing that a photocopy of this authorization be accepted with the same authority as the original. I hereby release from liability all representatives of Absolute Health Services for their acts performed in good faith and without malice in connection with evaluating my application, credentials & qualifications. I hereby release from any liability all individuals and organizations who provide information to the above in good faith and without malice concerning my professional competence, ethics, character and other qualifications. I understand that I am subject to Absolute Hospice's requirements for successful completion of our Volunteer acceptance process, which may include drug screens, background investigation, motor vehicle checks and reference checks. Note: Any contact with patient/family or patient medical file warrants a criminal background check per Medicare Hospice Regulations. My signature reflects that I have read, understood, and have agreed to these terms and conditions.

Thank you so much! Our Volunteer Coordinator will be in touch!

Volunteer Application