Hospice Volunteer Application

Pre-selection notes:

PLEASE RETURN APPLICATION TO: MultiCare Good Samaritan Hospice/Volunteers 3901 S. Fife St., PO 5299, MS 3901-1-HH, Tacoma, WA 98415

By submitting this application to Hospice Volunteer Services you are agreeing that your services are being provided without contemplation of compensation. Hospice Volunteer Application

Opportunities for volunteers are provided without regard to race, religion, sex, national origin, age, sensory, mental or physical disability, marital status, veteran’s status or sexual preference.

Last Name First Name Middle Name

Mr. Ms. Mrs. Miss Dr ______Preferred nickname: ______

Birth Date ______/______/______

Home Address

Street Address Apartment Number

City State Zip

Home Phone Number Business Phone Number E-mail Address ( ) ( )

I prefer to receive calls at Home Business Either Other ______

Have you lived in the State of Washington for more than three years? Yes No How long? Emergency Contact 1

Name Home Phone Number ( )

Relationship Business Phone Number ( )

Best way to reach: Home Business Either Other ______2

Name Home Phone Number ( )

Relationship Business Phone Number ( )

Best way to reach: Home Business Either Other ______Employment/Education Information

I am: Employed Education: High school student My employer offers a time-off program for volunteers Retired High school graduate My employer offers a donation matching program Student Undergraduate degree ______Graduate degree

Employer’s Name (or school) Occupation

CHILD AND ADULT ABUSE INFORMATION ACT Under a law passed in the 1987 Washington State Legislature, candidates for volunteer positions who will or may have unsupervised access and who will or may be directly responsible for the care, supervision or treatment of children or developmentally disabled persons must make a written disclosure of certain civil adjudications, convictions, records of crimes against persons and crimes related to drugs. Background inquiries on these matters will be made to the Washington State Patrol or to other state or federal law enforcement agencies.

Information obtained from the candidates disclosure statement or from these background inquiries will not necessarily prevent volunteering. This information will be considered in determining the candidate’s character, suitability and competence to perform and may result in a denial of volunteering. All candidates must sign a release authorizing the background inquiry. Failure to do so, or to provide the disclosure statement, shall prevent the candidate from volunteering.

Disclosure Statement

Pursuant to the requirements of 1987 Washington Chapter 486, we must ask you to complete the following disclosure statement. Answer all questions then provide your signature at the bottom. This information will be kept confidential.

1. Have you ever been convicted of a crime against children or other persons or crimes related to drugs? YES NO

(These crimes include any of the following offenses: aggravated murder; first or second degree murder; first or second degree kidnapping; first, second, or third degree assault; first, second or third degree rape; first, second, or third degree statutory rape; first or second degree robbery; first degree arson; first degree burglary; first or second degree manslaughter; first or second degree extortion; indecent liberties; incest; vehicular homicide; first degree promoting prostitution; communication with a minor; unlawful imprisonment; simple assault; sexual exploitation of minors; first or second degree criminal mistreatment; child abuse or neglect as defined in RCW 26.44.020; first or second degree custodial interference; first or second degree custodial sexual misconduct; malicious harassment; first or second degree child molestation; first or second degree sexual misconduct with a minor; patronizing a juvenile prostitute; child abandonment; promoting pornography; selling or distributing erotic materials to minors; custodial assault; violation of child abuse restraining order; child buying or selling; prostitution; felony indecent exposure; criminal abandonment; manufacturing a controlled substance; delivery of a controlled substance; possession of a controlled substance with intent to manufacture or deliver; or any of these crimes as they may be renamed in the future.)

If your answer is “YES”, please describe and provide the date(s) of the conviction(s) and the sentence(s) imposed. ______

2. Have you ever been found in a (a.) Dependency action, (b.) Domestic relations proceeding, or (c.) Disciplinary board final decision To have sexually assaulted or exploited a minor, or to have sexually abused a minor? YES NO

If your answer is “YES”, please describe the circumstance(s) and provide the date(s) of the finding(s) and the penalty(ies) imposed. ______

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Please provide us with the information requested below. This information shall only be used for the purpose of identification in conjunction with the background inquiry.

SEX HEIGHT WEIGHT COLOR OF EYES COLOR OF HAIR RACE SOCIAL SECURITY NO. DATE OF BIRTH

We may request your fingerprints to obtain from the Washington State Patrol criminal identification system a report of your record of criminal convictions for offenses against children or other persons, civil adjudications of child abuse, crimes related to drugs, and disciplinary board final decisions. If you are placed before that report is available, you will be notified of the State Patrol’s response within ten days after we receive the report. We will make a copy of the report available to you upon your request.

YOUR VOLUNTEER POSITION WILL BE CONDITIONED UPON THE RECEIPT OF A SATISFACTORY REPORT

We may also require your fingerprints to obtain from the Washington State Patrol criminal identification system a report of your record of criminal convictions for offenses against persons, civil adjudications of child abuse, and disciplinary board final decisions. We will make a copy of the report available to you upon your request. ______Identified areas of interest (non-direct patient care may not require Hospice Core Curriculum Completion), please circle:

Patient/Family Care Other specialized areas of service: Clerical Licensed Massage Therapist, Aromatherapist, Art Mailings Therapy, Counseling, Licensed Nail Artist, Events Hairdresser Marketing Recruitment Other ______Data Entry Life Review Transportation Gardening/Home Repair Playing an instrument or singing Art or Arts and Crafts

______

Do you know any languages other than English? Yes No

Language______Speak Read Write

Do you have access to transportation? Yes No

Why do you want to be a hospice volunteer? ______

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What qualities do you feel you can incorporate into your hospice volunteer work? ______

Death and Dying

What are your thoughts and feelings about death? ______

Have you ever been with someone at the time of their death? Yes No If Yes, briefly describe: ______

Have you ever provided care to anyone who was dying? Yes No If Yes, please explain: ______

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 expected of me.

I understand that any information that is disclosed to me while assisting MultiCare Hospice is confidential.

I interpret “volunteer” to mean that I have agreed to work without compensation in money. If accepted into the Volunteer Program as a volunteer worker, I expect to do my work according to the standards set forth in the Volunteer Policies and Procedures.

SIGNATURE MAIDEN NAME

NAME: (Please Print Exact Legal Name) OTHER NAMES BY WHICH HAVE BEEN KNOWN

DATE: Driver’s license #

UNDER PENALTY OF PERJURY, I certify that all the above information is true, correct and complete. I understand that if I am placed, I can be discharged for any misrepresentation or omission in the above statement. I also understand that if I am placed, my volunteer position is conditioned on receipt of a satisfactory report from the Washington State Patrol.

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