Johnston Health > Donate & Volunteer > Hospice Volunteer Application Hospice Volunteer Application Step 1 of 3 33% General InformationName First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home PhoneCell PhoneWork PhoneEmail Best time to contact you Morning Afternoon Evening Best number to use Home Work Cell Are you over 18 years of age? Yes No Have you experienced the loss of a loved one in the past 12 months? Yes No Has one of your family members ever received Hospice care? Yes No EducationHave you received a high school diploma? Yes No High School graduation yearCollege completed: Undergraduate studies (years completed) 1 2 3 4 College completed: Graduate studies (years completed) 1 2 3 4 Course of StudyDegree Received Previous EmploymentAre you currently employed outside the home? Yes No If yes, please list your place of employment.Have you ever served in the armed forces? Yes No Volunteer ExperienceName of Organization, Dates, Type of ServiceName of Organization, Dates, Type of ServiceName of Organization, Dates, Type of ServiceHave you ever received training as a Hospice volunteer? Yes No If yes, where did you receive this training? In what year?References(Work related if possible)Name First Last PhoneRelationshipYears AcquiantedName First Last PhoneRelationshipYears Acquianted Areas of InterestDirect Care cheer calls care cards respite care bereavement deliveries interpreter Indirect Care sewing baking flower arranging donate needed items fill gift baskets photography Adminstrative clerical publicity/public speaking fundraising Licensed/Certified accountant attorney carpenter child care dental care electrician hair stylist manicurist masseuse notary nurse (RN) plumber veterinarian other (explain below.) (Must have a license/certificate issued in the state of North Carolina.) Certificate #, Date Issued, Expiration DateAvailibilityHospice volunteers work 2 - 3 hour shifts on a weekly basis. Are there particular days/times that prefer you to volunteer?How did you hear about our Hospice Program? self volunteer/employee flyer/mailer church newspaper radio TV Applicant SignatureBy typing my full name above, I understand that this is an application for volunteer service and not a contract for employment with Johnston Home Care & Hospice or the SECU Hospice House. I certify that the information I have provided is true and a complete statement of the facts to the best of my knowledge and belief. Johnston Health considers applicants without regard to race, color, religion, creed, national origin, age, disability, sexual orientation, marital status, handicap or any other legally protected status.