Lakeland Hospice & Home Care Inc.

Lakeland Hospice and Home Care Application 120 South Union Avenue Fergus Falls, MN 56537 1-800-998-1400
Fields marked with * (asterisk) are required!
Name: *
Address: *
Home Phone: *	Cell Phone:	Work Phone:
Phone Number Format: (ex. xxx-xxx-xxxx)
How did you learn of volunteer opportunities for Lakeland Hospice and Home Care? *
Why do you want to be a volunteer for Hospice? *
Have you experienced the loss of someone significant in your life this past year? If yes, please explain

EXPERIENCE
Volunteer Experience
Organization:
Length of Service:	Position Held:
Address:
Phone:	Contact Person:

Organization:
Length of Service:	Position Held:
Address:
Phone:	Contact Person:

Work Experience
Most Recent Employer:
Start Date:	Position Held:
Address:
Phone:	Contact Person:

Personal References (Excluding family members) References will be contacted
Name:	Phone:
Address:
Relationship:

Name:	Phone:
Address:
Relationship:

Name:	Phone:
Address:
Relationship:

Please Note: Given the sensitive nature of our patient's conditions and the information our Volunteer's come into contact with, permission for a Criminal Background Check will be requested. Confidentiality is very important in the Health Care Field. As a result, you will be asked to sign a confidentiality Agreement.