Volunteer Interest Form Your generosity of time and kindness means the world to the one who receives it! Personal Information Contact Information Current Address Describe Yourself 1. Are you 18 years of age or older?: Yes No 2. Do you have any sensory or speech impairment?: Yes No 3. If yes, are communication aides needed?: Yes No 4. List any languages you speak besides English: 5. Have you ever been convicted of a crime?: Yes No 6. How did you hear about the Ziba Hospice Volunteer Program?: 7. What type of volunteer service/work are you interested in providing?: Patient Visits and Care Marketing or Education Office Assistance Bereavement Care 8. What qualities, skills, training, knowledge, experiences, hobbies, and interests do you feel you can incorporate into your volunteer work? 9. Describe your availability 10. Why do you want to volunteer with Ziba Hospice? 11. Describe your understanding of Hospice Death and Dying End of life care is not only difficult for patients and families, but for the healthcare workers that support them as well. The following are questions regarding your sensitivity to the concepts of death and dying. 1. Briefly describe your thoughts and feelings about death? 2. Have you experienced a significant loss in the past year? Yes No 3. Have you ever been with someone at the time of their death? 4. Have you ever provided care to anyone dying? 5. When thinking of your own death, what words best describe death to you? Heavy Natural Dark Frightening Lonely Joyful Peaceful Sorrowful I do not think about my own death Additional Comments Code of Ethics for Volunteers As a volunteer, I realize that 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 certain responsibilities and expect to account for what I do in terms of what is I understand that any information that is disclosed to me while assisting the Hospice is confidential. I interpret “volunteer” to mean that I have agreed to work without any compensation in money. Having been accepted as a volunteer worker, I expect to do my work according to the standards set forth in the Volunteer Policies and Procedures. 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 I authorize inquiries to be made concerning my employment, character, and public records for the 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 client information I acquire in the course of my volunteer activities with Hospice.