Waco Texas Hospice Care Terminally Ill End-of-Life

Fields marked with a red dot ( ) are required to complete this form.

First Name:  

Middle Initial:

Last Name:  

Maiden Name:

Email:  

Street Address:

Address (2nd):

City:

State:

Select a State Alaska Alabama Arkansas American Samoa Arizona California Colorado Connecticut District of Columbia Delaware Florida Federated States of Micronesia Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Northern Mariana Islands Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia US Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming

Zip Code:

 [5 digits]

Home Phone:

 (xxx) xxx-xxxx

Best Time to Call:

Cell Phone:

 (xxx) xxx-xxxx

This inquiry is for:

Myself Parent Friend Other

Comments and Questions

Any physical limitation/health problems that would interfere with your ability to volunteer?
YesNo

If yes, please explain:

Has someone close to you died in the last 12 months?
YesNo

If yes, please explain:

Do you have access to a car?
YesNo

Do you carry at least $100,000 / $300,000 in personal liability insurance?
YesNo

Why do you wish to volunteer:

Day(s) available to volunteer:

Hours available to volunteer:

Signature:  

Date of Application:

I am willing to adhere to the rules and regulations of Providence Hospice to the best of my ability.
I agree to respect the Client's right to confidentiality. I will attend orientation and training.
I understand that I will begin service on a reciprocal trial basis.