Hospice Volunteer Application

Thank you for your interest in becoming a hospice volunteer. The following information will provide us with a clear understanding of your abilities and interests and will help us to best utilize your skills and interests.

General Information

Name *

Address *

Home Phone Number *

Work Phone Number

Email Address

Are you over 18 years of age? *

Yes
No

Are you currently enrolled in school? *

Yes
No

If you are enrolled in school, are you enrolled part-time or full-time? *

Part-Time
Full-Time
I'm not enrolled in school.

Employer

Position/Hours

Briefly describe the type of work you do.

How did you hear about volunteering with Hospice? *

Community Presentation
Radio
Family
Friend
Newspaper
Church
Other (Please complete the next question.)

If you selected "Other" in the previous question, please indicate how you heard about volunteering for Hospice.

Please indicate the DAYTIME hours for which you are able to volunteer. (Please type "none" if you do not have daytime availability.) *

Please indicate the EVENING hours for which you are able to volunteer. (Please type "none" if you do not have evening availability.) *

Please indicate the WEEKEND hours for which you are able to volunteer. (Please type "none" if you do not have weekend availability.) *

Personal Information

Describe your motives for becoming a volunteer: *

Describe your particular interests, skills or knowledge that relate to volunteering: *

Describe your personal losses within the last year *

Describe your views about life and death: *

Describe your spiritual values: *

What kinds of volunteer work are you interested in (check all that apply): *

Relieve Primary Caregivers In Their Home
Medication Delivery
Companionship
On-Call
Bereavement
Hospice Inpatient Unit
Shopping/Errands
Baskets of Love
Nursing Home
Other (Please complete the next question.)

If you selected "Other" in the previous question, please indicate other areas of interest.

In Case of Emergency

Emergency Contact Name *

Emergency Contact Address *

Emergency Contact Home Phone Number *

Emergency Contact Home Work Number

Emergency Contact's Relationship to You *

Personal Reference #1

Reference #1 Name *

Reference #1 Address *

Reference #1 Home Phone Number *

Reference #1 Work Phone Number