CarePartners Volunteer Application CarePartners Volunteer Application Status New Completed Archived Contact Information First Name * Last Name * Middle Name Title Director Dr. Elder Mrs. Miss Ms. Mr. Rev Other Title Nickname Street 1 * Street 2 Street 3 City * State * North Carolina Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Section Home Phone * OK to call me here Section Work Phone OK to call me here Section Cell Phone OK to call me here Email * What kinds of email would you like to receive? Electronic Newsletters Information Updates Availability Days and Times Available * Please give your specific availability on each day (Sunday through Saturday) specific to the half hour. My availability is * Ongoing Ongoing, except between these dates Only between these dates From * Please enter the date when your availability begins. To * Please enter the date when your availability ends. Number of Hours * Please enter the number of hours you are willing to serve. Frequency * One Time Daily Weekly Monthly Please select the frequency of the number of hours just entered. Experience & Interests Work & Volunteer Experience Please list previous jobs and volunteer roles. Indicate if each role was as a paid employee or a volunteer. CarePartners Experience Have you ever been employed by/volunteered with CarePartners or a Mission Health system affiliate? If yes, list position and dates. Work History Have you ever been dismissed or forced to resign from any job or volunteer position? If yes, please explain. Current Enrollment Status Are you currently enrolled at a college or university? If yes, list school and course of study. Skills and Interests * Cash Register/Retail Sailes Customer Service Clerical Skills Fluent in a language other than English Computer Skills OtherOther Preferences * Clerical Project/Work Patient Interaction - None Physical Activity - None Visitor Interaction - Extensive Computer - Extensive Assignment Patient Interaction - Extensive Physical Activity - Extensive Short-Term Special Project Visitor Interaction - Limited Computer - Light Data Entry Patient Interaction - Limited Physical Activity - Limited Solitary Work Projects Your ideas about specific volunteer placement areas: Why do you want to be a volunteer? How did you hear of us? References Please use references who have known you at least one (1) year. Do NOT list physicians, relatives or anyone living with you. Provide complete mailing address, email addresses are preferred. Reference 1 First Name * Last Name * Address * City * State * North Carolina Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Home Phone * Cell Phone Email * Relationship * Reference 2 First Name * Last Name * Address * City * State * North Carolina Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Home Phone * Cell Phone Email * Relationship * Reference 3 First Name * Last Name * Address * City * State * North Carolina Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Home Phone * Cell Phone Email * Relationship * Vaccination Requirements All Mission Team Members, including volunteers, must comply with Mission Health's vaccination policies. A vaccination screening appointment with Mission WorkWell will be scheduled as part of the intake process. Please be ready to produce any available immunization records. Current policy requires: Varicella (chicken pox) vaccine or proof of immunity Tetanus, Diphtheria & Pertussis (tdap) vaccine Measles, Mumps & Rubella (MMR) vaccine or proof of immunity (those born before January 1, 1957 are exempt from MMR vaccine) Influenza vaccine for the current flu season Tuberculosis screening Volunteer Agreement I hereby certify that the answers on this application and any resultant interviews are true and correct, and that any misrepresentation or omission of facts, misleading or false information on my part will be grounds for dismissal as a volunteer. Acceptance as a volunteer is contingent upon satisfactory references, verification of the information submitted on this application, compliance with vaccination requirements and a criminal record check. I, therefore, authorize you make such investigations and inquiries you deem necessary in arriving at a decision. I acknowledge and agree that I am not obligated, if called upon, to perform the volunteer services herein applied for, and CarePartners Hospice Volunteer Team is not obligated to assign or actively seek to assign volunteer services for me. I authorize that all employers, schools, or references thus contacted be released from all liability in answering questions related to my application. I Agree * reCAPTCHA Submit