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Volunteer Application





















Are you 16 years of age or older?

Have you ever been convicted of a crime?


Do you have any impairments—physical, mental, or medical—which would interfere with your ability to perform volunteer
duties for which you have applied?



Military History




Identified Areas of Interest

Administrative

Availability: When are you available? (Please check all that apply)

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Saturdays

Sundays

Background/Preferences



Death and Dying

Have you ever provided care to anyone who was dying ?




References

List names/addresses of three persons not related to you whom you have known at least one year. HPCI will be contacting the following references.

1









2









3









I authorize Heavenly Hands & Palliative Care, Inc. to contact the above-listed persons for the purpose of obtaining references. I understand all information will be kept confidential and release from liability any person giving or receiving information.

In addition, I understand I will be required to sign an affidavit authorizing Heavenly Hands & Palliative Care, Inc./Heavenly Hands & Palliative Care, Inc.’s contracted agency to conduct a criminal background check.

I understand and agree that any material misrepresentation or deliberate omission of a fact in my application may be justification for refusal of, or if activated as HPCI volunteer, termination from volunteerism.