Volunteer Application

Legal First Name *

Middle Name

Legal Last Name *

Date of Birth

Street Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Preferred Phone *

Emergency Contact *

Emergency Contact Phone *

Relationship

Please Share With Us

Do you have previous hospice and/or hospice volunteer experience? What do you hope to gain from your volunteer experience? Please describe below.

Volunteering areas of interest

Working directly with patients
working in the office (not with patients)
Working on special events and fundraising events
Grief support

Describe other skills and interests. *

Emergency have Last

Have you experienced the loss of someone close to you in the past 12 months? *

Yes
No

It is Centrica Care Navigators's policy to require a one-year waiting period for volunteer applicants who have experienced the loss of a loved one. If someone close to you has died, we are very sorry about your loss. We recognize that you have a lot to offer as a volunteer and we look forward to connecting with you after the waiting period.

If yes, and you would like to share, please describe your loss here.

Have you served in the military?

Yes
No

Are you able to perform the functions of the volunteer role, with or without accommodations? *

Yes, with no accommodations
Yes, with some accommodations

How did you learn of volunteer opportunities at Centrica Care Navigators? *

Criminal Background Check

Centrica Care Navigators regrets that an individual who has been convicted of a felony, or who has charges pending, is not eligible to volunteer. Misdemeanor convictions will be assessed according to Centrica Care Navigators Criminal Background Check Policy (available upon request). This is a secure website. Your answers are confidential.

Have you ever filed a volunteer application with Centrica Care Navigators?

Yes
No

If yes, when?

Application Submission

I certify that the facts in this application are true and complete to the best of my knowledge and understand that falsified statements on this application may result in termination as a volunteer. I understand and agree that my volunteering is for no definite period and may be terminated with or without cause, at any time, with or without notice.

I also understand that I must complete volunteer training before being given an assignment. I am willing to participate in Centrica Care Navigators’s ongoing in-service activities for volunteers.

I certify that I am able to perform the essential duties of the volunteer position that I accept. In the event that I have a disability that will affect my ability to take an assignment, I will inform Centrica Care Navigators prior so that reasonable accommodations can be made. Centrica Care Navigators reserves the right to require medical documentation regarding the need for accommodation.

I authorize investigation of all statements contained in this application. I release the listed references to provide you with any and all applicable information they may have. I hereby release these references from all liability for any information they may give to Centrica Care Navigators.

I agree to the above statement. *

Yes

Click on the "Submit Your Application" button below to complete your application.

Please Share With Us

Criminal Background Check

Application Submission

For group volunteer opportunities, call 269.345.0273

See our events