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Service Area

We serve in west-central Indiana in a 60-mile radius from our main office in Danville, Indiana.

List of serviced counties
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Volunteer Application

Personal Information

Full Name: *

Date:

Street Address *

Address continued

City *

State *

Zip *

Home Phone #:

(
)

Work Phone #: *

Best time to call

Occupation *

Place of Employment *

How did you learn about Horizon Hospice Care, Inc? *

Why are you interested in volunteering for Horizon Hospice Care, Inc? *

Summarize any special skills, hobbies and creative abilities you have to offer:

Has someone in your immediate family passed away within the last year? *
Yes
No

Do you have your own means of transportation? *
Yes
No

If no, how would you perform your volunteer responsibilities?

If yes, do you have auto insurance? (If yes, please provide a copy of your vehicle insurance card)
Yes
No

Which areas of hospice service do you prefer?

Patient / Family Contact

Office Work (filing, copying, etc)

Public Relations (speaking, fund-raising)

Other

Please specify

State any additional comments you feel may be helpful in considering your application:

In case of emergency notify (first)

Name: *

Relationship: *

Home Phone #:

(
)

Work Phone #:

(
)

In case of emergency notify (second)

Name: *

Relationship: *

Home Phone #:

(
)

Work Phone #:

(
)

Applicant’s statement

I CERTIFY THAT ANSWERS GIVEN HEREIN ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION FOR VOLUNTEER WORK AS MAY BE NECESSARY IN ARRIVING AT A DECISION.

I agree to the above applicant’s statement. *
Yes
No

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