Contact Us
Please fill out the following information and submit.
Name of Applicant:
Date of Birth:
SS#
Address
City
Zip
Home Phone
Work Phone
Employer
Occupation
Can receive calls at work:
Yes
No
Emergency Only
Person to be notified in an emergency
Name
Phone
Address
City
Zip
Education/Special Training
Work Experience
Are you currently a volunteer in any other home care of hospice agency?
Yes
No
If Yes, please list
Personal References
(excluding family members)
. Please provide a complete address, as references are verified by mail.
Name
Phone
Address
City
Zip
Name
Phone
Address
City
Zip
Volunteer's Area of Intrest:
Patient/Family Care
In Home
In Nursing Home
In Facility
Transportation
Personal Care
Meal Delivery
Alternative Therapies
Bereavement
Caller
Home Visits
Support Group Co-Facilitator
Transportation
Office/Clerical
Memorial Service Committee
Non-Patient Services
Clerical
Fundraising
Mailings
Events
Marketing
Courier
Switchboard
Data Entry
Do you know a language other than English?
Yes
No
Language
Speak
Read
Write
Do you have access to transportation?
Yes
No
What qualities (skills, talents, knowledge, and experiences) do you feel you can incorporate into your hospice volunteer work?
Death and Dying
What are your thoughts and feelings about death?
Have you ever been with someone at the time of their death
Yes
No
If yes, please describe briefly:
Have you ever provided care to anyone who was dying?
Yes
No
If yes, please describe briefly:
When thinking of your own death, what words best describe death to you?
I do not think about my own death
sorrowful
natural
frightening
painful
lonely
joyful
heavy
peaceful
dark
Other
Comments
