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Kaiser Permanente Martinez Hospice Volunteer Program

Thank you for your interest in becoming a hospice volunteer. Please complete the following information.

Print or write clearly and carefully.

Name: __________________________________ Date of Birth: ________ (Month/day only)

Address: __________________________________________________________________________________

City: ____________________________________________________ Zip Code: _________________________

Email Address: ______________________________________________ Home phone____________________

Employer: ______________________________________________ Work Phone: _______________________

Other phone numbers (Cell, Fax, etc) ___________________________________________________________

Education completed: _______________________ Field of Study: ____________________________________

SS#:________________ Driver License #: _________________ Kaiser Permanente ID #: __________________

Previous volunteer experience:

Languages Spoken: _____ _____________________________ Written: __ ______________________________

Hobbies, special interests: ____________________________________________________________________

Availability: Weekdays: _____________________ Weekends: ____________ Times: _____________________

Specifics: (i.e. geographic location) _ ____________________________________________________________

Have you ever been convicted of a crime? ________ If yes, explain when, where and disposition of case:

Please list type of volunteer work you prefer/do not prefer (e.g. direct patient volunteering (visits, errands), office assistance, bereavement, special talents, other:

Are you available to volunteer four hours a week, if needed? Yes No

Can you make a 1 year commitment to volunteering after completing the training? Yes No Not sure

Emergency notification: Name: _________________________________________ Phone:_______________

Physician: _______________________________________________________ Phone:__________________

Please provide two (2) Letters of Recommendation (employer, co-worker, friend, etc.)

Signature: Print & Sign_______________________________________________________

Date: ______________________

Return your completed Application and Letters of Recommendation to the address below. If you have any

questions, please call the Hospice Volunteer Coordinator at (925) 229-7816

Kaiser Permanente Martinez Hospice Program Attn: Volunteer Coordinator 200 Muir Road Martinez, CA 94553 DSA My Doctor Online - Hospice Updated 06-15-2016

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