Application

 

We’re so glad you’re interested in becoming a hospice volunteer.

The application below was designed to evoke responses about issues that are central to this work. We tried to keep it to two pages, but please feel free to use as much space as you need – just add pages.

The cost of training is $45.  Please mail your signed application and the fee to us at 34 Old County Road, Rockport, ME  04856.  We will be in touch about setting up at phone interview after that.

Just one caveat … we ask that you give yourself a full year after the death of someone close to you before you apply for our training class.  We ask our volunteers to take time to heal and adjust after loss, and it’s especially important for potential volunteers to do so as well.

Thank you again for your interest. We look forward to meeting you.

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Name ____________________________________________________

Mailing address_____________________________________________

Home phone _____________   cell _____________ work ____________

Email ____________________________________________________

Date of birth _________________________

Occupation ________________________________________________

Employer ____________________________________

May we call you at work? (circle one)       yes         no        emergency only

Person to be notified in an emergency

Name ________________________ _____________________

Home phone _____________   cell _____________ work ____________

Two personal references

1. Name __________________________________________________

Mailing address_____________________________________________

Home phone _____________   cell _____________ work ____________

Email ____________________________________________________

2. Name __________________________________________________

Mailing address_____________________________________________

Home phone _____________   cell _____________ work ____________

Email ____________________________________________________

 

Please write a brief autobiographical sketch, including your personal and professional history, along with your education, any special training, skills and hobbies.  (Feel free to use additional pages for this or any question below.)

How did you hear about our hospice volunteer program?

Why do you want to be a hospice volunteer?

What are your greatest strengths? What are your greatest weaknesses?

If you have strong feelings and/or opinions (political, religious, personal), can you quiet them and listen to others without judging their thought processes or offering advice?

Would you summarize your thoughts and feelings about death?

Have you cared for someone who was dying, or been with them at the time of death?  If yes, please describe briefly ….

How available and flexible can you be in meeting the needs of patients and families?

Please note: A TB test is required and provided at no charge by PenBay Healthcare. Please call Amy Moody, our contact in employee health, 593-5577, to schedule your test.

CODE OF ETHICS FOR VOLUNTEERS

As a volunteer, I understand I am subject to a code of ethics similar to that which binds the professionals in the field in which I will work. I, like they, assume certain responsibilities and expect to account for what I do in terms of what is expected of me.

I understand that any information disclosed to me while assisting Coastal Family Hospice Volunteers (CFHV) is confidential. I understand “volunteer” to mean that I have agreed to work without compensation in money. Once accepted as a volunteer worker, I expect to do my work according to the standards set forth in CFHV’s policy and procedure handbook.

DECLARATION

I hereby certify that the statements made on this application are true and correct to the best of my knowledge. I understand that by submitting this application I authorize inquiries to be made concerning my employment, character and public records for the purpose of determining my suitability as a volunteer. I affirm that I have read the Code of Ethics for Volunteers (above) and agree to abide by its regulations. I agree to respect the confidentiality of any client information I acquire in the course of my activities with Coastal Family Hospice Volunteers.

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Applicant Signature                                                                                          Date