Contact Information

Name:*

First Last

Address:*

Street Address Address Line 2 City State ZIP Code

Home Phone:*

Work Phone:*

Email:*

Your Birth Date:*

Are you over 18 years old?*

Yes

Person to Notify in Case of Emergency

Name:*

First Last

Address:*

Street Address Address Line 2 City State ZIP Code

Home Phone:*

Work Phone:*

Email*

Availability

When would you like to start?

During which hours are you available for volunteer assignments?

Weekday mornings

Weekday afternoons

Weekday evenings

Weekend mornings

Weekend afternoons

Weekend evenings

Special Skills or Qualifications

Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports.

Hospice Applicant Only

Have you experienced any deaths in your family or of anyone close to you?

Please explain your relationship to the person and when they died.

Previous Volunteer Experience:

Summarize your previous volunteer experience.

Long Term Care and Hospice Opportunities

Is there a particular type of volunteer work in which you are interested?

Volunteer Type - Other:

References

Please list the names of two references not related to you whom you have known at least one year.

Reference #1 - Name:*

First Last

Phone:*

Address:*

Street Address Address Line 2 City State ZIP Code

Reference #2 - Name:*

First Last

Phone:*

Address:*

Street Address Address Line 2 City State ZIP Code

Medical Information

Have you had a TB test in the last year?*

If yes, was it by blood draw or skin test?*

If no, are you willing to get one?*

Have you had a flu shot?*

If not, are you willing to get one?*

Consent to Background Check

Are you willing to consent to a background check?*

Yes

Agreement and Signature

Your signature indicates that the facts contained in this application are true and complete to the best of your knowledge. If employed as a volunteer, falsified statements on this application shall be grounds for dismissal. You authorize Stella Maris to investigate your personal background, qualifications, and references. You acknowledge that it is policy of Stella Maris not to share information obtained from such investigation with applicant in order to promote full and frank disclosure information.

You understand that Stella Maris is not obligated to provide placement for you nor are you obligated to accept the position offered.

Signature:

Volunteer Application

Contact Information

Person to Notify in Case of Emergency

Availability

Special Skills or Qualifications

***Hospice Applicant Only***

Previous Volunteer Experience:

***Long Term Care and Hospice Opportunities***

References

***Medical Information***

***Consent to Background Check***

Agreement and Signature

Hospice Applicant Only

Long Term Care and Hospice Opportunities

Medical Information

Consent to Background Check