Online Volunteer Application
Name:
Address line:  
City: State: Zip Code:
Phone:

Are you at least 18 years of age or older? (Anyone under the age of 18 will not be assigned to direct patient care) Yes: No:

Person to contact in case of emergency: Phone:
Educational Background:

Occupation/Work Experience:
Volunteer Experience:
Area of Personal Interest
(Hobbies, Social Activities, Etc.):
Experiences of serious illness
in your family or a close relationship
(who, how long ago, etc.):
Why do you want to become a volunteer?
Do you have any limitation on your ability
to perform the duties of a volunteer?		 Yes: No:
If yes, please describe the conditions
and the nature of your limitations:
Have you ever been convicted of a felony: Yes: No:
If yes, please state the nature of the
crime(s), when and where convicted
and the disposition of the case:

Please indicate any foreign languages you can speak, read and/or write:

Language 1: Speak: Fluent: Fair: Poor:
    Read: Fluent: Fair: Poor:
    Write: Fluent: Fair: Poor:
Language 2: Speak: Fluent: Fair: Poor:
    Read: Fluent: Fair: Poor:
    Write: Fluent: Fair: Poor:
Language 3: Speak: Fluent: Fair: Poor:
    Read: Fluent: Fair: Poor:
    Write: Fluent: Fair: Poor:
Please summarize any special skills and qualifications you acquired from
employment or other experience:

REFERENCES

Please list below three people, not relatives, who have know you either personally or professionally for longer than 1 year. Please have two of these people write a letter of reference on your behalf and return to Visiting Nurse and Hospice Care of Santa Barbara, Attention Linda Martin, Coordinator of Volunteers, 222 E. Canon Perdido Street, Santa Barbara, CA 93101.

Reference 1
Name:  
Address line:  
City: State: Zip Code:
Phone:
Number Years Acquainted:  
Nature of Relationship:  
Reference 2
Name:  
Address line:  
City: State: Zip Code:
Phone:
Number Years Acquainted:  
Nature of Relationship:  
Reference 3
Name:  
Address line:  
City: State: Zip Code:
Phone:
Number Years Acquainted:  
Nature of Relationship:  

*Referrals will not be accepted from relatives or individuals currently enrolled in hospice training.

PLEASE READ BELOW AND ACKNOWLEDGING THAT YOU HAVE READ AND AGREE TO THE TERMS STATED

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment as a volunteer shall be grounds for rejection of this application or for immediate discharge if I am accepted as a volunteer, regardless of the time elapsed before discovery.

I hereby authorize Visiting Nurse & Hospice Care of Santa Barbara to thoroughly investigate my references, work record, and other matters related to my suitability for employment and, further, authorize my former and current employers to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

I understand that nothing contained in the application or conveyed during any interview which may be granted is intended to create an employment contract for volunteering between me and the company. In addition, I understand and agree that if I am accepted as a volunteer, my volunteer status is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and company’s designated representative.

I have read above terms and
agree to them: 		Yes: No:
Date:
 
To find out more about how to become a volunteer, please call us at 805 965-5555 in Santa Barbara and 805 693-5555 in Santa Ynez and Lompoc Valleys or click here