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South Carolina
–
Columbia
– CCH|Columbia VOLUNTEER APPLICATION
I. Personal Information
We are an Equal Opportunity Employer, dedicated to a policy of non-discrimination in employment on any basis including age, sex, color, race, creed, national origin, religious persuasion, marital status, political belief, or disability that does not prohibit performance of essential job functions.
First name
*
Middle name
Last name
*
Current address (street address, city, state, zip)
*
Permanent address (street address, city, state, zip)
(If different than Current address.)
Email
*
Primary phone
*
Select phone type
*
Home
Cell
Work
Secondary phone
Select phone type
Home
Cell
Work
Select preferred method of contact
*
Primary phone
Secondary phone
Email
Availability
I am able to volunteer:
*
(Check all that apply.)
Mornings
Afternoons
Evenings
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays
Emergency contact
Name
*
Relationship to you
*
Address (street address, city, state, zip)
*
Primary phone
*
Select phone type
*
Home
Cell
Work
Secondary phone
Select phone type
Home
Cell
Work
Federal law prohibits the employment of unauthorized aliens. All persons hired must submit satisfactory proof of employment authorization and identity (valid driver's license, birth certificate, green card, etc.) within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination.
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II. Interests and Experiences
Please check all areas of interest to you:
*
Patient/Family Care - Home Care
Clinical (i.e., Massage Therapist, Reiki Massage, Music Therapy, Art Therapy)
Patient/Family Care - Long Term Care
Professional Services (i.e., Attorney, Hair Stylist, Notary, Interpreter)
Administrative/Office
Handcrafts (i.e., Knitting, Crocheting, Sewing, etc.)
Certified Pet Visitors
Special Events
Other areas of interests not listed above:
Please describe any work or other experience which you feel has prepared you to be a Hospice Volunteer:
*
Personal Loss
Have you experienced a personal loss within the last 12 months?
*
Yes
No
If yes, please provide date and person's relationship to you.
Please briefly explain any significant losses you have experienced that influence your views of death and dying. Include when these losses occurred and your relationship to the deceased.
*
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III. Educational History
Select highest level of education completed:
High School
College
Graduate School
Post-graduate
IV. Employment History
Occupation
(Or former occupation, if retired. May include student or homemaker, if applicable.)
Company Name
Company address (street address, city, state, zip)
V. Professional Licenses and/or Certifications
List any you have received below.
V. Referral Source
How were you referred to Compassionate Care Hospice?
*
(Check all that apply.)
Friend
Internet Search
Family
Volunteer Website
CCH Employee
CCH Website (cchnet.net)
Place of Worship
School
Library
Other referral sources not listed above:
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VII. Personal References
(Provide a minimum of two references. Please do not include relatives.)
Name
*
Years known
*
Address (street address, city, state, zip)
*
Phone
*
Name
*
Years known
*
Address (street address, city, state, zip)
*
Phone
*
Name
Years known
Address (street address, city, state, zip)
Phone
Volunteer opportunities are open to all qualified applicants without regard to race, color, religion, sex, national origin, age, handicap/disability or Veteran status.
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Statements
Have you ever been convicted of a felony?
*
Yes
No
If yes, please explain below:
Sworn statement
I certify that the information contained in this application is true and complete to the best of my knowledge and acknowledge that any misrepresentation, falsification or mission herein shall be sufficient reason for dismissal from or refusal of Volunteer Services.
Digital signature
*
(Type your name in the box above. By doing so, you are providing a digital signature confirming the sworn statement above.)
Date
*
TO SUBMIT APPLICATION CORRECTLY: YOU MUST ENTER A VERIFICATION CODE BELOW.
Once submitted successfully, you will see a message reading: "Your application was successfully submitted. Thank you for your application. We will be contacting you shortly."
Verification
Please enter any two digits with no spaces (Example: 12)
*
This box is for spam protection -
please leave it blank
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