Volunteer Application - Reverence Home Health & Hospice


Please complete the following form in its entirety.

Where would you like to volunteer?


1. PERSONAL INFORMATION:

First and Last Name:


Street Address:

City:

State:

Postal Code:

E-mail Address:

Telephone #:

Work Telephone #:

Cell Phone #:

Best time to reach you by phone:


2. REASON YOU ARE APPLYING FOR VOLUNTEER WORK:






How did you hear about this volunteering opportunity?


3. EXPERIENCE WITH SERIOUS ILLNESS
The last death of someone close to me was:



Relationship:

Why have you chose to volunteer with Reverence Home Health & Hospice?


Have you ever been with someone at the time of their death?



4. AVAILABILITY:
Length of time available to volunteer?


  If Other, please specify:
How often:



  If Other, please specify:

Select the times you would be available to volunteer by clicking the corresponding box.
Monday |
Tuesday |
Wednesday |
Thursday |
Friday |
Saturday |
Sunday |

Please check your area(s) of interest:





5. VOLUNTEER EXPERIENCE:
Please list any current and prior volunteer experience: including clubs, church, school projects...


Hobbies / special interests:


6. EMERGENCY CONTACT:
Name:

Street Address:

Telephone #:

Relationship:


GENERAL INFORMATION:
7. Are you under 18 years of age?
If Yes, please list your age and birth date:

8. Have you ever volunteered or been employed at a Reverence Home Health & Hospice?

If Yes, please indicate position:


9. Have you ever been convicted of a crime?
If Yes, please complete the following:


Date

Where

Charge

Disposition

Please Explain


10.PERSONAL REFERENCES: Please list at least two references other than relatives or employees (You must have complete mailing address, including zip code.)

Reference 1
Name:

Address:

City, State, Zip:

Relationship:

Years Known:


Reference 2
Name:

Address:

City, State, Zip:

Relationship:

Years Known:



ACKNOWLEDGEMENT:
I hereby affirm that the information provided on this application is true and complete to the best of my knowledge. I understand a misrepresentation of facts constitutes cause of separation.

If placed I will volunteer on a regular basis, be dependable, and honor all Genesys Health System and volunteer policies and guidelines. I hereby authorize present and former employers, associates, schools, credit organizations, law enforcement agencies, military organizations, and/or other persons to provide Genesys Health System with any information which may aid in determining my suitability for volunteering. Additionally, I release those individuals and/or organizations contacted from all liability whatsoever for issuing the requested information, and hereby waive my right to receive written notice of any such information provided. I also hereby release Genesys Health System, its affiliates and employees from any and all liability and damages for requesting, releasing and using information concerning me, my work and performance record.

It is clearly understood that there is no employer/employee relationship and that as a support volunteer I am not entitled to compensation or fringe benefits of any kind for voluntary services.

By submitting this application on-line, I agree to the above written statement.

A telephone interview will be scheduled when your completed application is recieved


 

Coming Up

[More events]

In the News

03/03/2016
Reverence Home Health & Hospice receives award of excellence

12/16/2015
Pediatric Hospice suite opens in Grand Blanc

10/31/2014
Reverence receives top-performing home health recognition

[More News Releases]

Careers at Reverence

Search our listing of available postions and apply online.

About Reverence

What is Home Care and Hospice?
Our Volunteers
Our Support Groups
Our Mission and Hospice Philosophy

Notice of Non-Discrimination:


Locations

Borgess Health
Genesys Health System
St. John Providence
St. Joseph Health System
St. Mary's of Michigan

Contact Us

888-2-HOMECARE (888-246-6322)
5445 Ali Drive
Grand Blanc, MI 48439
Fax : 877-561-7891

Copyright 2014. All Rights Reserved.