Mount Carmel Health System

Because of You

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Hospice Volunteer Application

* Indicates required information
Name * 
Address * 
City * 
Zip * 
Home Phone 
Work Phone 
Cell Phone 
Email Address * 
Volunteer Position 





Emergency Contact 
Name 
Phone 
Volunteer History 
Agency 
Dates Worked 
Description of Work 
Agency 
Dates Worked 
Description of Work 
Work History 
Employer 
Date of Employment 
Description of Work 
Special skills, abilities, training, experience, hobbies, or interests that you would be willing to share with our patients/families 
What are you hoping to gain by being a hospice volunteer?  
What personal bereavement have you experienced within the past year? (death, loss, separation)  
Are you willing to commit to a year with our program? 
Are you willing to go through the complete training we offer? 
Are you willing to attend continuing education sessions? 
Are you a veteran? 
Branch 
Please List Two Personal References Other Than Relatives: 
Name 
Years Known 
Address 
City 
Zip 
Name 
Years Known 
Address 
City 
Zip 
The Volunteer Office will mail a reference form to the persons listed above. Your signature below is your consent to send the inquiries. 
Electronic Signature of Applicant 
Date  (mm/dd/yyyy)
Please note that according to the Medicare Conditions of Participation, the laws for the State of Ohio, and the policy of Mount Carmel Hospice, the Hospice Volunteer Office will conduct a Criminal Background and ask you to submit to a drug screen. Your si 
Electronic Signature of Applicant 
Date  (mm/dd/yyyy)
Authentication * 

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For more information about Mount Carmel Hospice, call 614-234-0200.


©  2014  

Mount Carmel Health System  |  Columbus, Ohio

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