Volunteer Application Form

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Applicant Information

First Name: *

Last Name: *

City:

State:

Zip:

Birthdate:

Daytime Phone:

Evening Phone:

Email:

Two Personal References

First Reference(excluding family members). Please provide a complete address, as references are verified by mail.

First Name: *

Last Name: *

City:

State:

Zip:

Daytime Phone:

Evening Phone:

Email:

Second Reference

First Name: *

Last Name: *

City:

State:

Zip:

Daytime Phone:

Evening Phone:

Email:

How did you hear about our Hospice Volunteer Program?:

Why do you want to be a Hospice Volunteer?:

Please list any skills, talents, knowledge and/or experiences you feel you can incorporate into your hospice volunteer work :

Life Choice Hospice does not sell, share, or rent its email or mailing lists with any other company. All information is strictly confidential.

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800-557-7570

Serving Pennsylvania, New Jersey, and Massachusetts

Services are provided and referrals are performed regardless of race, color, national origin, creed, religion, gender, sexual orientation, age,
diagnosis, disability or ability to pay.

Life Choice Hospice is JCAHO accredited in PA, NJ & OH. Joint Commission provides a hotline for patients, their families, caregivers and others to share concerns regarding quality of care or safety at this accredited organization. Staff members from the Joint Commission are available to answer your call on weekdays between 8:30am and 5:00pm, in the Central Time Zone. Their toll-free line is available 24 hours a day, 7 days a week: (800) 994-6610

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