Volunteer Application

*Required field(s) are indicated by an .**
Personal Data
* First Name
* Last Name
* Mailing address
* City
* State
* Zip
* Daytime Phone
Home Phone
* Email
Employer
Occupation

May you be contacted at work?	Yes No
Do you have a valid OK driver's license?	Yes No
Would a car be available to you for hospice work?	Yes No
Have you ever been convicted of a felony?	Yes No
Please provide two (2) personal references (excluding relatives). Please include complete address, phone number and relationship
Name
Address
City
State
Zip
Phone
Relationship

Name
Address
City
State
Zip
Phone
Relationship
Additional Information
Emergency Contact
Address
Phone
Relationship
Doctor's Name
Doctor's Phone

List any training or skill
List any licenses or certifications you have obtained
Languages
English	Yes No
Other	Yes No
Language	Speak Read Write
Language	Speak Read Write
Areas of Interest Patient/Family Care
Companionship/Visits
Errands/Shopping
Transportation
Light Housekeeping
Yard Work
Fix-it Projects
Relief for the Caregiver
Grief Assistance Services
Office/clerical
Telephone Work
Grief Companion
Home Visits
Memorial Services
Non-Patient Services
Office/clerical
Fill in Receptionist
Computer skills
Baking for events
Photography
Speaker's Bureau
Other
How were you referred to Hospice of Green Country?

Availability to Volunteer
Daytime	Evenings Weekends
Comments
Has someone close to you recently died?	Yes No
If yes, please briefly explain
Were they a hospice patient?	Yes No
Have you ever been a caregiver to anyone?	Yes No
If yes, please briefly explain
CODE OF ETHICS As a volunteer, I realize that I am subject to a code of ethics similar to that which binds professionals in the field in which I work. I, like them, assume certain responsibilities and expect to account for what I do in terms of what is expected of me. I understand that any information that is disclosed to me while assisting Hospice of Green Country, Inc. is confidential. Hospice of Green Country performs a criminal background check for all potential volunteers and employees to ensure that the highest quality of care and consideration is shown to our patients and families. DECLARATION: I 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 agree to respect the confidentiality of any patient information I acquire in the course of my volunteer activities with Hospice of Green Country, Inc. I understand that I if I am accepted as a Hospice of Green Country volunteer, I will be offered and required to complete volunteer training.
*	Please check this box if you agree to the above terms and conditions
Thank you for your interest in the Volunteer Services program at Hospice of Green Country. Volunteers play a vital role in providing hospice services to the community. Volunteers are greatly appreciated by patients, families and staff of our agency.

Hospice of Green Country, Inc.
1120 S. Boston, Suite 200 • Tulsa, OK 74119
phone: (918) 747-2273 • fax: (918) 747-2573

Northeast office
653 W. Claremore Street • Claremore, OK 74017
phone: (918) 342-1222 • Fax: (918) 342-8191

Southwest office
19 N. Main • Sapulpa, OK 74066
phone: (918) 224-7403