Volunteer Application

Please complete the form below and click submit. This information will be held in confidence and will be used only by Hospice of Palm Beach County, Inc.:

Thank you for your interest in volunteering for Hospice of Palm Beach County, Inc.

First Name: *
Last Name: *
Street: *
City: *
State: *	Choose A State Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip: *
Email Address:
Phone: *
Date of Birth:
Place of Employment:
	Full-time Part-time
Work Phone:
Position:
Days/hours you work:
Drivers License #:
Drivers License State:
Auto Insurance Co:
Policy Number:
Expiration Date:
In case of emergency contact:
Emergency contact phone number:
Availability to volunteer: Year Round Seasonal
Specify Months:
Education: (please check highest level completed)
High School Some College Degree Post Graduate
Please check any that apply to you:
MD MSW RN Counselor LPN Clergy CNA Other
Professional License Number:
Have you done volunteer work before? No Yes
Where?
Has a member of your immediate family or a significant other died in the past year? No  Yes
Have you ever been a caregiver for someone who has died? No Yes
When?
Relationship:
How did you hear about Hospice of Palm Beach County, Inc.?
Have you ever been convicted of a felony? No  Yes
By submitting this form you are affirming that the information you have provided is true and correct.