Hospice Volunteer Application

Please create your desired User ID and Password above.

(User ID must be a valid email)

For help contact:

Essentia Health East Volunteer Services 407 East Fourth Street Duluth, MN 55805 (218)786-4420

Hospice Volunteer Application

Volunteer Services Mission Statement

Volunteer Services is dedicated to provide the highest

quality of volunteer support to those we serve within the region

**Please advise us if any accommodation is needed to participate in the application process.**

Person Type

Personal Information

* Family/last name

* First name

* Middle name

* DOB

* Address

* City

* State

* Zip/postal

* E-mail

* Primary Phone

Secondary Phone

Essentia Health no longer requires volunteers to be vaccinated for COVID-19, but does require that volunteers share their vaccination status to comply with National Hospital Safety Network regulatory reporting requirements.

Are you up to date* with your COVID-19 vaccinations? (Yes/No) *People aged 5-64 years are considered up to date when you have one age-appropriate updated COVID-19 vaccine. *People aged 65 years or older are up to date when you have received two updated 2023-2024 COVID-19 vaccine doses.  

Emergency Contact

* Contact name

* Primary Phone

Secondary Phone

* Relationship to Volunteer

Education and Work Experience

Position/Responsibilities

Work Phone

Grade Level

Post Secondary School (if applicable)

Did you graduate?

Have you ever been employed by Essentia Health?

From

To

Facility/Department

Your Name at the time

Can you commit to volunteering at a regular scheduled time?

* How did you hear about volunteering?

* Why do you want to volunteer?

Reference 1:

Name

Day Time Phone

Complete Address

City

State

Zip/postal

Name

Day Time Phone

Complete Address

City

State

Zip/postal

___________________________________________________________________________________________________________________

I hereby authorize investigation of all statements contained in this application. I further authorize my reference permission to furnish Essentia Health East with facts and opinions as to my job performance, capabilities and desirability as a volunteer. I further release all persons whomsoever from any damage because of furnishing said information.

* The information in this application is accurate and correct to the best of my knowledge.

I agree as a volunteer my time and talents will be given freely without any expectation of monetary reimbursement.

I am participating in a community program, which reimburses me for volunteer service hours.

* My typed name shall have the same force and effect as my written signature.

* Your Signature

* Date

Volunteer opportunities are provided without regard to religion, creed, race, national origin, sexual orientation, age, gender, disability, marital status or status with regard to public assistance. Essentia Health East does not imply that you will be assigned a volunteer position and this application should not be construed as a contract or promise of a volunteer position.

Hospice Volunteer Form 2016