Volunteer Application - Magnolia Hospice

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Thank you for your interest in volunteering with Magnolia Hospice. The following information helps provide us with a clear understanding of your skills and interests, and will help us when making volunteer assignments. Magnolia does not discriminate in volunteer recruitment, training, or assignment practices based on race, color, creed, gender, national origin, disability, marital status, sexual orientation, or age.

Location to Apply to

First Name

Last Name

Cell Phone

Birth Date

Email Address

Address

City

State

Zip Code

Volunteer Information

Please note that your volunteer eligibility and authorization to work in the U.S. will be verified.

Describe any past volunteer history and/or licenses/certificates you hold:

What draws you to volunteer with hospice?

Criminal Background Inquiry

Have you ever been convicted of a crime, other than a minor traffic offense, or pled no contest to a crime?

Yes No

If yes, please explain.

Emergency Contact

Name

Home Phone

Work Phone

Address

Relationship to You

“I certify that the facts contained in this application are true and complete and to the best of my knowledge and I understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information they may have, personal or otherwise, and release all parties from all liability for damage that may result from furnishing same to you.”

CCS is an EOE and provides services without regard to race, color, national origin, sex, religion, age and disability.

Signature

Date