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Hospice Volunteer Application
Date:
Name:
First
Last
Address:
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*
Are you 18 years of age or older?
Yes
No
Employer(s) (List past 3 years, Occupation/Position and Year(s))
Why do you want to be a hospice volunteer?
Please list any previous volunteer experiences:
Talents or Hobbies:
Education/training or special skills:
How did you hear about Celtic Hospice?
What geographic area would you like to service?
Western PA North - Allegheny, Butler, Beaver
Western PA South - Fayette, Washington, Westmoreland
Central PA - Carlisle, Cumberland, Perry, Dauphin
Northeast PA - Wilkes Barre, Scranton
Any specific areas within these geograpic locations?
What time schedule is best for you?
Daytime
Evening
Weekend
Do you have access to an automobile?
Yes
No
Volunteer activities may require the use of a vehicle. A current Pennsylvania Driver's License and proof of insurance will be required.
What type of volunteer service are you interested in providing? Please check your preference(s).
Direct Patient Contact
Administrative Tasks
Bereavement Support
Direct Patient Contact:
This includes such activities as: companionship, socialization, running errands, light housekeeping, meal preparation, transportation, emotional support, etc.
Administrative Tasks:
This includes assembling mailings, writing condolence cards and special projects.
Bereavement Support:
This is accomplished through viewings at funeral homes and outreach to the families.
Please provide two references (no relatives) that you have known at least one year.
1. Name:
First
Last
Address
Street Address
City
Zip / Postal Code
Phone:
Relationship:
2. Name:
First
Last
Address:
Street Address
City
Zip / Postal Code
Phone:
Relationship:
I understand as a volunteer I will not be entitled to monetary compensation for the work I perform or be entitled to Worker's Compensation or Group Benefits in the event of an injury. As a volunteer, I realize that I am subject to a code of ethics similar to that which binds the professionals in the field in which I volunteer. I understand that any information that is disclosed to me while assisting as a Hospice Volunteer is confidential.
Signature:
Date:
If you have any questions or need
additional information, please contact:
Oxsana Byczkalo
Volunteer Coordinator for Western PA
byczkaloo@celtichealthcare.com
Cindy Kunst
Volunteer Coordinator for Central PA
kunstc@celtichealthcare.com
Kelly McAndrews
Volunteer Coordinator for Northeast PA
mcandrewsk@celtichealthcare.com
Please return form by submitting button below or mail to:
Hospice Volunteer Program
Celtic Healthcare, Inc.
150 Sharberry Lane
Mars, PA 16046
FAX: 724-625-4288
Ministry of Presence
Commonly Asked Questions
Stories of Compassion
Family Resources
Hospice Volunteer Program
Hospice Volunteer Application
Blog/News
What is Hospice?
Complimentary Whitepaper
What to Expect When Your Physician Suggests Hospice
Email:
Blog/News
Appreciating our Hospice Volunteers
How can I Help my Friend or Loved One Deal with Grief?
How Can I Help My Child(ren) Deal with Grief?
How Do I Deal with this Grief?
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