Volunteer Application Details

Personal Data Title First name Last name Middle name

Referral How were you referred to Cornerstone Hospice

Volunteer Qualifiers

400 Characters Max Why are you interested in volunteering for Cornerstone Hospice?

400 Characters Max What qualities do you possess and volunteer experiences have you had that would make you a good volunteer?

Select All That Apply What are your areas of volunteer interest? (Check all that apply) Home Care Respite Bereavment Phone Support Music Partner Inpatient Care Special Events Errands/Transportation Clerical Support

Select One Are you able to provide regular availability and commit two to four hours each week? yes No

Select All That Apply When are you able to provide your volunteer service? Weekdays Weekends Seasonal Evenings Flexible

Select All That Apply When are you able to attend the 24-hour training program (weekdays only)? Days Evenings Flexible

Select All That Apply Have you suffered a significant loss recently? Death Divorce Career Move Other

400 Characters Max How do you feel you are coping with the change / loss?

Additional Information

Other than Arizona, where have you lived in the last three years? What is your educational background?

Select One Are you employed? yes No

Select One Are you retired? yes No

Select One May we call you at work? yes No

Select One Does your employer provide volunteer matching benefits? yes No

Select One Are you a student at this time? yes No

Select One Are you fluent in a foreign language? yes No If so, what languages?

What are your interests, hobbies, skills? In what groups / organizations do you have membership? Drivers License State and Number Auto Insurance Policy Provider and Policy Number

Select One Have you been convicted of or served time for a felony?* yes No If so, when and where?

*Felony conviction will not necessarily disqualify applicant from volunteering. Convictions are evaluated in relation to the position applied for.

Non-Family Referances

Reference One Name Daytime Contact Number Address Relationship Years Known

Reference Two Name Daytime Contact Number Address Relationship Years Known

Reference Three Name Daytime Contact Number Address Relationship Years Known

Optional

We consider applicants for volunteering without regard to race, color, religion, national origin, sexual orientation, age or disability. Answering the following questions is optional and all information is confidential. The information will be used to gather collective demographic information on volunteerism.

Select One Gender? Male Female

Select One Age group? 18 - 30 31 - 45 46 - 60 61 - 75 over 75

Select One Race/Ethnic group? African American American Indian/Alaskan Native Asian/Pacific Islander Caucasian Hispanic Other

400 Characters Max Please share with us any pertinent information about yourself or your family that you would like us to know: