How did you hear about our hospice volunteer program?

Why do you want to be a hospice volunteer?

What skills, talents, knowledge, and/or experiences do you feel you can inforporate into your hospice volunteer work?

What type of volunteering interests you?

Consent to Driving Record Review

In consideration of Life Choice Hospice's review of my application for volunteering, I consent to having my driving record reviewed by entering my driving license number below. I hereby release any individual, entity, and Life Choice Hospice, Inc. from all claims or liabilities that might arises from that review or the disclosure of its results, including claims under any federal, state or local civil rights laws, and any claims for defamation or invasion of privacy.

License # State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Consent to Criminal Background Check

I understand that as part of the volunteer requirements, a Criminal Background check will be conducted on me with the report to be furnished to Life Choice Hospice. The information requested and provided on this form will only be used for purposes of completing any required background check in compliance with
Pennsylvania law. Applicant’s living in the Commonwealth of Pennsylvania for the past two (2) years will have their background checked through the
Pennsylvania State Police Criminal History Record Check system. An applicant who has not resided in Pennsylvania or who has not been a resident for the past two (2) years shall be required to obtain Criminal History Background Check from the Federal Bureau of Investigation within 90 days of provisional volunteering.
I have been a resident of the Commonwealth of Pennsylvania for the entire two years (without interruption) immediately preceding the date of application.
I have not resided or been a resident of the Commonwealth of Pennsylvania for the entire two years (without interruption) immediately preceding the date of application. Until such time that the criminal history report submitted to the facility, not in excess of the time permitted by law, the volunteer will be
considered a provisional volunteer.

To be completed by those who have not resided or been a resident of the Commonwealth of Pennsylvania for the entire two years (without interruption) immediately proceeding the date of application. List previous residences (other than in Pennsylvania) Please continue list if necessary.