Hospice of the Piedmont Volunteer Application

Hospice of the Piedmont considers volunteer applicants for all positions regardless of race, color, religion, creed, gender, national origin, age, disability, marital, or veteran status, or any other legally protected status.

New User Details

User ID

User ID (verify)

Password

Password (verify)

Age Verification

Hospice of the Piedmont requires volunteers be18 years of age or older. Are you 18 or older?

Since you indicated you are under the age of 18 your application will not be processed due to all volunteers needing to be 18 or older. Thank you for your interest in applying. Please contact us at 434-817-6911 if you have any questions.

Personal Information

Name

* Legal first name

* Legal last name

Preferred First name

Perferred Pronouns

Do you have preferred pronouns?

Feel free to list your pronouns here.

Address

* Address Line 1

Address Line 2

* City

State

* Zip

Contact Information

* Phone Number (Mobile/Cell)

* E-mail Address

Emergency Contact

* Contact name

* Relationship

* Phone (Mobile/Cell)

Additional Information

Volunteer source

* Please list the name of the volunteer you know.

* Volunteer Source: Other

Are you a Veteran?

Branch of Service:

Are you a student?

Do you speak any additional languages?

Do you have current certifications and wish to offer that as a volunteer service?

Please enter any other certifications you may have below.

* Why do you wish to volunteer with Hospice of the Piedmont?

* Most Recent Work/Volunteer History (describe duties)

* Other hobbies, interests, skills or experiences you bring to hospice work.

Other organizations or civic groups you feel are pertinent.

* Have you experienced a significant loss in the last 1-2 years?

* How do you handle/cope with stress?

References

List three (3) persons to whom you are not related and who have known you for several years, preferably people familiar with your work skills.

Reference 1

* First and Last Name

* E-mail

Reference 2

* First and Last Name

* E-mail

Reference 3

* First and Last Name

* E-mail

Applicant's Statement

I certify that answers given herein are true and complete. I authorize investigation of all statements contained in this volunteer application as may be necessary in determining acceptance in a volunteer capacity. In the event of becoming a hospice volunteer, I understand that false or misleading information given in my application or interview(s) may result in termination of volunteer status. I also agree to a criminal background check and give permission for the above references to be contacted. I understand, also, that I am required to abide by all rules and regulations of Hospice of the Piedmont.

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Applicant's Signature