• Name:
• Address:
• Social Security #:
• Date of Birth * MM / DD / YYYY
• School:
• Grade:
• Cell:
• Email:
• Parent or Legal Guardian:
• Parents Work Phone: Mother
• Father
• Parents Cell Phone: Mother
• Father
• Person to be Notified in Case of Emergency:
• Relationship:
• Phone:
li id="foli16" class=""> Do you have any restrictions which might affect your volunteer placement with Hospice?:
Yes No
• Family Physician:
• Physician Phone:
• Organizations to which you belong:
  '.$_POST['OrgsBelong'].'
• Honors you have recieved and/or positions you have held in organizations:
  '.$_POST['OrgsBelong'].'
• Why you want to volunteer for Hospice:
  '.$_POST['OrgsBelong'].'
• Which volunteer role/s are you interested in?:
  Office Work Hospice House Nursing Homes & Assisted Living Facilities Community Events Speaker's Bureaus Children's Camp Pet Therapy Horticultural Therapy Other

This consent form is provided to the parents/guardians of teen volunteers under the age of 18. Because you play an important role in your child’s experience as a hospice volunteer, this form is intended to inform you of policies and procedures. We ask that you read this with your child and sign the statement below. * Universal Precautions, taken by medical personnel when working with all patients, are taught to your child during volunteer training. You are asked to indicate below your decision in regard to your child being placed with a patient who has a known communicable disease. * All patient information is to be kept confidential. Your child has signed a Statement of Confidentiality. We recognize that your child will benefit from sharing volunteer experiences with you. For this reason, we ask that you sign the Parent/Guardian Statement of Confidentiality below. * Your child is required to complete and return a Volunteer Report form after each patient/family visit. This documentation becomes part of the medical records, which Hospice relies on for the patient’s plan of care and for government funding. CONSENT By submitting this form, I do hereby consent for my teen to participate as a Cornerstone Hospice Volunteer.

• Name of Teen Volunteer:
• Parent/Guardian Name:
• PATIENTS WITH KNOWN COMMUNICABLE DISEASES
• Please check below to indicate that you grant or deny permission for your child to be assigned to a patient with a known communicable disease.:
  I GRANT permission I DO NOT grant permission
• PARENT/GUARDIAN STATEMENT OF CONFIDENTIALITY
• I understand the importance of patient confidentiality related to my child’s Hospice volunteer service and agree to keep in confidence any information that may be shared with me.
  Parent/Guardian Name

• List three professional references of persons not related to you whom you have known at least one year. Name:
• Telephone#:
• Occupation:
• Address:
• Name:
• Telephone#:
• Occupation:
• Address:
• Name:
• Telephone#:
• Occupation:
• Address:
• Have you had a tuberculosis screening test (PPD) in the last 12 months?:
  Y N
• If yes, what were the results?:
  Positive Negative