Volunteer Application

Lynchburg Hospice

2097 Langhorne Road, Lynchburg, VA 24501

434-200-3093

Farmville Hospice

1705 East Third Street, Farmville, VA 23901

(434) 315-5050

Bedford Hospice

1621 Whitfield Drive #C, Bedford, VA 24523

(540) 587- 6592

Personal information

First

Last

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

How long have you been at this address?

If less than 2 years, where did you live before this address?

Date of birth

(Teens must be 16 years old to volunteer)

Preferred phone

Email address

Emergency contact

Name

Relationship

Phone number

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Desired area of interest

Administrative service

Phone receptionist

Greeting visitors and answering phone

Office duties

Filing

Mailings

Gardening (Bedford Hospice House)

Serve on Centra Hospice's Veteran's Committee

Special projects

Offsite service

Calling patients and caregivers

Sending cards to patients and caregivers

Phone support (comfort calls)

Volunteer information

How frequently are you able to volunteer?

Once a week

Twice a week

Once a month

Twice a month

Occasionally for special projects

Have you volunteered before?

Yes

Where?

Have you ever been an employee of Centra?

Relationship to individual

Date of death

Employer

Work number

Part time or full time?

Retired?

Previous occupation

College graduate?

Yes

High school graduate?

Yes

Area of study

Highest level/ degree obtained

Other professional training/ licensure

If you are in school now, please provide the name of your school and the year you plan to graduate

Is volunteer work a requirement of your school?

Yes

References (2 non-related)

First

Last

Address

City/Town

State/Province

ZIP/Postal Code

First

Last

Address

City/Town

State/Province

ZIP/Postal Code

Human Resources Information

Have you ever been convicted of a felony?

Yes

If so, please explain

Have you ever been ordered to perform court-ordered community service?

Yes

A criminal background check will be conducted.
Mini Health Check and requirements will be scheduled after orientation with employee health.

Applicant's certification and agreement

I certify that the information given by me in the application is true and complete in all respects and understand any falsifications or omissions shall be sufficient cause for dismissal from or refusal of volunteer status.

I authorize my former employers, and persons listed as references on this application to furnish any information concerning my personal character, habits, employment record, and previous volunteer experience. I release all such persons from any liability or damages incurred because of responding to our inquiry and furnished this information to us. If accepted as a volunteer, I may terminate my volunteer service at any time without notice or cause. Likewise, the Volunteer Services Department may terminate or modify the relationship at any time without notice or cause

Volunteer's electronic signature

The purpose of Volunteer Services is to serve Centra Hospice in a positive manner, to enhance the well-being of patients, caregivers and to support the Hospice staff.

I understand that due to the expended investment of time and financial resources in the on boarding and training of new volunteers, Volunteer Services requests a minimum of 50 hrs. per year commitment from volunteers. Volunteer Services may refer perspective volunteers to other community volunteer programs if the minimum time requested is not possible.
I understand that during my volunteer week I may be exposed to information of a confidential nature pertaining to patients and/or their families. I will consider as confidential all information which I may hear directly or indirectly and will not seek information regarding a patient, except as it pertains to my volunteer assignment. I agree to uphold the traditions and standards of this hospice and to safeguard its reputation by maintaining the highest standards of confidentiality.
I agree to adhere to the department’s reporting hours and visits procedures each time that I volunteer.
I agree not to engage in any manner of religious, commercial, or political solicitation while in the hospice duty or on hospice property.
I agree to uphold the Customer Service Standards as outlined in my orientation (safety, confidentiality, teamwork, professional behavior, and accountability.
I understand that the Hospice Volunteer Services reserves the right to dismiss my volunteer status at any time without notice or cause because of (a) failure to comply with organizational policies, rules, and regulations; (b) absences without prior notification; (c) unsatisfactory attitude, work, or (d) any other circumstances which, in the sole judgment of the department staff, would make my continued service as a volunteer contrary to the best interests of the organization.

I have read each of the above conditions, and I agree to be bound by them.

Electronic signature

Electronic signature date

If volunteer is under 18 years of age, parent's signature

Parent signature date