Volunteer Form

Contact Information

Name
Mailing Address
City
State
Zip
Home Phone #
Work Phone #
Cell Phone #
Email Address

Employment

Employed
Employer
Occupation

Education

Education or Special Training
*If a Nurse:*
NC Certificate #
Expiration Date
*If a CNA:*
NC Certificate #
Expiration Date

History

Brief description of work history

Other experiences

(volunteer work, interests, special skills, abilities, hobbies)

Have you experienced the death of a family member or close friend within recent years? If so, please provide a brief comment about the experience

References

List 4 references. (Please complete all information.)

*1st Reference:*
Name
Mailing Address
City
State
Zip
Phone #
*2nd Reference:*
Name
Mailing Address
City
State
Zip
Phone #
*3rd Reference:*
Name
Mailing Address
City
State
Zip
Phone #
*4th Reference:*
Name
Mailing Address
City
State
Zip
Phone #

North Carolina Residency Have you lived in North Carolina consecutively for the past 5 years?

Yes
No

If No, where did you live before coming to North Carolina?

Do you have a valid driver's license

Yes
No

Have you been convicted of any major driving offenses within the past 5 years, other than a traffic violation?

Yes
No

Any traffic charges pending at this time?

	Yes No
If Yes, please explain:

Emergency Contact

Person to notify in case of emergency:

Name
Relationship
Address
City
State
Zip
Home Phone #
Work Phone #

Agreement

I verify that the above information is correct, and I give permission for Caldwell Hospice and Palliative Care, Inc. to contact current and former employers and references, as it deems appropriate. I further understand that I may be afforded the opportunity to begin volunteer services with Caldwell Hospice and Palliative Care, Inc., prior to the completion of my background investigation (criminal history and motor vehicle records).

Signature	(Type your name to acknowledge.)
Date

Advance Care Planning

About Hospice

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