First Name Last Name Street Address City State MN AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zipcode Email Birthday (mm/dd/yy) MN Drivers License Number Home phone number Work phone Cell phone How would you prefer to be contacted? Home Cell Work Email Can we email you at this address? In case of emergency, please contact: First Name Last Name Relationship Phone number First Name Last Name Relationship Phone number Do you have any special interests, skills or foreign language abilities you would like to utilize as a volunteer? How did you learn about Quiet Oaks Hospice House? Current volunteer Family member was a patient at Quiet Oaks Church Radio or newspaper Other Briefly describe why you want to volunteer at Quiet Oaks Hospice House.
If you have previous experience as a hospice volunteer or any other type of volunteer, please list the services you provided. Where? What, if any certifications/licenses do you currently hold? What volunteer categories are you most interested in serving? House volunteer: hospitality, food prep, maintenance, cleaning (2+ shifts/month) Kitchen: meal prep, cooking, baking, cleaning after meals Outdoor work/gardening (seasonal) Special projects (occasional) If you chose special projects, please describe your area of interest (administrative, help with mailings, events, light repairs, play piano, spring cleaning, etc.) How often do you wish to volunteer? Weekly Twice a month Monthly Occasionally Days of the week you are available: Sunday Monday Tuesday Wednesday Thursday Friday Saturday Time of day you are available:
Morning (9-1) Aternoon (1-5) Evening (5-9) Any time If you would like to add any comments about your schedule, please do so here: As a Quiet Oaks Hospice House volunteer, you will regularly confront death. What support systems do you have in place to help you with these experiences? *Quiet Oaks Hospice House offers equal opportunity to all qualified individuals without regard to race, color, sex, age, national origin, religion or disability. The following information will assist us in selecting and adapting the volunteer job to better meet your needs and the needs of the hospice. Are there any health problems or physical disabilities you feel should be considered before placement as a volunteer? References: Please list three people that we may contact who are not related to you. First Name Last Name Street Address City State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zipcode Phone First Name Last Name Street Address City State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zipcode Phone First Name Last Name Street Address City State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zipcode Phone I hereby certify that I have not been convicted and/or found guilty of patient abuse, neglect, or mistreatment, or misappropriation of patient property in this state or in any state and that I am not listed in any resident or patient abuse registry in this state or any other state. I understand that any offer to become a volunteer at Quiet Oaks Hospice House is conditional upon verification of this information with the state patient abuse registry and that a listing on such a registry or registries of any other state may act as an automatic withdrawal of any such offer to become a volunteer.
I understand that Quiet Oaks Hospice House requires a thorough background investigation for all potential volunteers.
Please read “Privacy Notice MDH 09-2003”, using the link below.
This investigation is limited to only that information required in determining fitness for volunteering and may include, but is not limited to: Past employment history verification, job performance, disciplinary record, financial/credit history and a criminal background investigation. By affixing my signature to this document, I agree to hold harmless any previous employer, agent of that corporation, or any individual or organization providing information pursuant to this authorization.
I also understand that a TB screening test is required to become a volunteer and I agree to have it administered annually during my volunteer time with Quiet Oaks Hospice House.
I certify that I understand the above statements and that they are true.
I have read “Privacy Notice MDH 09-2003”.
I authorize Quiet Oaks Hospice House to contact listed references to verify information and I release each person from liability for providing information.
Applicant's Name Date Thank you so much for your interest in volunteering at Quiet Oaks! The Volunteer Coordinator will contact you within five business days.
