BBH AmeriCorps Legacy Corps Member Application

Contact Information

Volunteer First Name*

Volunteer Last Name*

Current Street Address*

City*

State*

Zip*

Cell Phone*

Preferred Email*

How Did You Hear About Us?

How did you hear about volunteering with BBH AmeriCorps? Hospice experience, hospice volunteer, website, brochure, newspaper, social media, presentation, community event, faith community, school/university…please be specific if possible.*

Demographics

Date of Birth*

Gender*

Lifestyle (Student, Working Part Time, Working Full Time, Seeking Employment, Retired):*

AmeriCorps members must be a United States citizen, U.S. national or lawful permanent resident. Are you a United States citizen, national, or lawful permanent resident?*

Yes
No

Skills & Experience

Please describe your volunteer experience, past or current.*

Please describe your professional experience, academic education or expertise in a certain field or vocation. If you are a current student, please include where, what you are studying, and when you hope to graduate:*

Please tell us the highest level of education that you will have completed by the time you plan to serve in AmeriCorps:*

Some High School
High School Diploma/GED
Technical School/Apprenticeship
Associate’s Degree
Some College
Bachelor’s Degree
Graduate Degree
Other

Do you know or have you studied any language other than English? Which language(s)?*

Do you have any hobbies, interests, or skills that you would like to share with our patients or our organization?

Availability

Please indicate the days and times you plan to be available to volunteer, between 8 am – 8 pm. Please note the families we serve have limited desire for volunteer support on the weekends, so weekday availability is preferred:*

Do you plan to be in the Tallahassee area for the full year of service, 9/1 through 8/31? Please tell us here about any currently planned travel or time away longer than a few weeks:*

Motivation

Why are you interested in our organization and the AmeriCorps Legacy Corps program? What you know about hospice care and palliative care? What do you hope to contribute and gain from your involvement?*

Are you willing to work with people without regard to race, gender, age, sexual orientation, religious creed, disability or marital status?*

Yes
No

Willing to submit to the required level 2 background screenings and national sex offender registry check (at no cost to you)?*

Yes
No

Willing to take the required 2 TB skin-prick screenings (at no cost to you)?*

Yes
No

Willing to provide proof of full COVID vaccination prior to beginning in-home service?*

Yes
No

And do you have reliable transportation?*

Yes
No

If you answered NO to any of the above questions, please elaborate:

Has anyone close to you died within the last year? Type YES or NO below. If YES, please elaborate:

Emergency Contact: In the event of an emergency whom should we notify?

First Name*

Last Name*

Relationship*

Home Phone*

Cell Phone*

Email*

Address*

Reference One (cannot be a relative)

First Name*

Last Name*

Relationship*

Phone*

Email*

Address*

Reference Two (cannot be a relative)

First Name*

Last Name*

Relationship*

Phone*

Email*

Address*

AmeriCorps Criminal History Questionnaire

The AmeriCorps application process requires a criminal history check to ensure community members with whom we work are protected, particularly children, individuals with disabilities, and individuals over 60 years old. We are investigating for past sexual offenses and violent crimes, or crimes that would have a direct bearing on your service. This background check will entail a search of the National Sex Offenders Public Registry and may include a statewide criminal history repository check and/or a FBI criminal history check, which will require you to submit fingerprints. You will not be permitted to serve or work with children, individuals with disabilities, or individuals over 60 years of age, without supervision, until the history check is complete and you are cleared. The review process is not lengthy, and normally is completed within weeks. Answer the following questions fully. Existence of a criminal conviction or juvenile adjudication may or may not, depending on circumstances, disqualify you from consideration. However, any intentional misrepresentation or omission is grounds for disqualification. Answer the following questions and include misdemeanors and any offense that led to pre-trial intervention and/or fines other than speeding or parking tickets: Have you ever been convicted as an adult, or adjudicated as a juvenile offender, of at least one criminal offense by either a civilian or military court?*

Yes
No

Are you currently facing charges for any offense, on probation or parole?*

Yes
No

If yes to any of the above, please elaborate here:

I AGREE

I understand and agree that submitting this application form does not automatically register me as a Big Bend Hospice AmeriCorps Member, and that there are certain qualifications I must meet to be selected for service, including the acceptance of established volunteer policies and procedures and screening clearance. I understand and agree that by submitting this application form that if I am selected as an AmeriCorps Member Volunteer I will be considered an unpaid employee of Big Bend Hospice, not eligible for worker’s compensation in the event of injury or illness that may result from my activities as a Big Bend Hospice volunteer. By signing this application, or by submitting it electronically if applying on-line, I certify that all of the statements made in this application are true, correct, and complete, to the best of my knowledge, and are made in good faith. Misinformation or omission of information could result in disqualification or termination as an AmeriCorps Member.