Volunteer

Volunteers help us live our mission in numerous ways from spending time with patients to helping in our office.

Whatever your talents, Homecare of Mid Missouri, has a need you can fill. Every day our volunteers make a real impact on the lives of others.

If you have a heart for volunteering please complete the form below.

Hospice Volunteer Application Form

Name

Date

Address

City

State

Zip

Cell Phone

Previous Volunteer Experience

Occupation (Past Occupation if retired)

Other information that will help us make a good match (such as education, general interests/hobbies)

Availability and Volunteer Assignment Preferences (Please Check All That Are Applicable) I Am Available

Mornings (Mon-Fri) Afternoons (Mon-Fri) Evenings (Mon-Fri) Weekends Once A Week More Than Once A Week One Time Only As Needed OTHER

I Could Serve More Than One Person

Yes No

Do You Have A Valid (State) Driver's License?

Yes No

License Number

Vehicle License Plate Number

Insurance Company

Policy Number

Policy Active Dates

Social Security Number

Date of Birth

Have You Ever Been Convicted For Violation Of Any Laws, Traffic or Otherwise?

Yes No

If Yes, Please Explain

Do You Have Any Physical Condition That May Limit Your Activities?

Yes No

If Yes, Describe

Who To Notify In Case Of An Emergency?

Telephone Number

Please list three persons we may call who are NOT family, one of whom may be your religious or spiritual leader, teacher, employer or relationship other than personal friend.

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

Comments

I hereby give my consent to contact my references; to contact my employers, past and present; and to conduct a background check.

Volunteer

Volunteer

Hospice Volunteer Application Form​

Hospice Volunteer Application Form