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Home Care / Hospice Care / Hospice Care Volunteer Form
 

Hospice Care Volunteer Form

To protect the safety and security of those we serve UR Medicine Home Care will conduct reference and background checks for all potential volunteers. Your signature on the Authorization of Disclosure form authorizes UR Medicine Home Care to conduct a background check to obtain information through criminal record inquiries, public records, and driving record.

If you would like to volunteer at one of the hospice locations UR Medicine Home Care services, please fill out the form below.

Your Information

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Employment Information

Can you be contacted at work?:

Education and Interests Information

Know any languages other than English?:

Emergency Contact Information

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Personal References

Please provide a completed address, as references are verified by mail. Please exclude family members.

First Reference

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Second Reference

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Areas of Interest

Patient or Family Care:

Non-Patient Services:
Do you have access to transportation?:
Have you ever provided care to someone who was dying?: