Become A Part of Something Amazing in Our Community ~ VOLUNTEERS NEEDED !

Please Read before completing this application:

This company does not discriminate in the recruitment, hiring, and conditions of employment (volunteering) on the basis of race, color, religion, national origin, sex, disability, age, or veteran status and any other applicable laws. Your completed application will be reviewed carefully. However, applying for Volunteer opportunities does not guarantee acceptance into this program. Volunteer consideration necessitates that you meet all minimum qualifications and requirements for the applied position.

PERSONAL DATA

Name: Phone/ Cell #:

Mailing Address:

Email Address:

OTHER

Employer/School Address:

Contact #:

Emergency Contact #1: Phone/Cell #:

Emergency Contact #2: Phone/Cell #:

Are you over the age of 18? Yes___ No___ If No, Are you 16 years of age? YES____

GENERAL INFORMATION

How were you referred to our company? _____

Specific name of referral source indicated above, if applicable: ____

When are you available to volunteer? ☐ Weekday ☐ Weekend(s) ☐ School Year ☐Other ____

Do you have access to reliable transportation?

☐ YES ☐ NO ☐ I Prefer to use public transportation.

☐ I Understand I will be required to provide a copy of my driver's license and liability coverage in the event I choose to use my own transportation for volunteering purposes as part of my employment records and requirements.

PREVIOUS VOLUNTEER EXPERIENCE:

Organization Type of Work:

Organization Type of Work:

REFERENCES (2): (Professional or personal)

(1) Name:

Relationship:

Time Known:

Address:

Email Address:

Phone/Cel l#:

(2) Name:

Relationship:

Time Known:

Address:

Email Address:

Phone/Cell #:

VOLUNTEER POSITION PREFERRED: (Please check boxes of interest)

☐ DIRECT PATIENT CARE

☐ Companionship/ Socialization/ Caregiver Relief

☐ Assistance with Meal Preparation/ Light Household Chores

☐ Spiritual/ Bereavement/ Emotional Support

☐ Vigil Volunteering (sitting with and attending to our actively dying patients)

☐ Veteran Volunteers

☐ Pet Therapy (requires certification of therapy animal)

☐ Enrichment Services (music/art)

☐ ADMINISTRATIVE SUPPORT (Data entry, filing, copying, assistance with mailings, etc.)

☐ OTHER: ________________________________________

Do you speak a foreign language? ☐ YES ☐ NO -Specify:

Are you an active service member/ Veteran? ☐ YES ☐ NO -Specify:

Other skills and interests?

CODE OF ETHICS:

As a Volunteer, I realize I am subject to a code of ethics similar to that which binds the professional in the field in which I work. I, like them, assume accountability for my work and will seek to fulfill my responsibilities to the best of my ability. I understand that any information disclosed to me while assisting Gentiva is confidential. I interpret my role as Volunteer to mean that I have agreed to work without monetary compensation. Having been accepted as a Volunteer, I will do my work according to the standards set forth in the Volunteer Orientation Manual and description. I agree to a background investigation. ☐

The background investigation and drug screening will be sent via email Certiphi Screening and must be completed start to finish within 30 days once the process has been initiated.

DECLARATION:

☐ I hereby certify that the statements made on this application are true and correct to the best of my knowledge. I understand that by submitting this application and consenting for a background investigation I am authorizing inquiries to be made concerning my employment, character, and public records for the sole purpose of determining my suitability as a Volunteer. I affirm that I have read the Volunteer Code of Ethics and agree to abide by its regulations. I agree to respect the confidentiality of any patient or family in the course of my Volunteer activities with Gentiva.

Signature:

Date:

☐ I agree that my electronic signature is equivalent to the signing of my handwritten/manual signature.

Printed/Typed Name: