Name:

Address:

City:     Zip:

Home Phone:      Cell/Work Phone:

E-mail Address:

What is the best way to contact you:

Date of Birth:

Are of 18 years of age or older? Yes  No

Emergency Contact Name:

Emergency Contact Phone Number:

Emergency Contact Relationship:

Areas of Interest:

Patient Companionship        Office/ Clerical
Patient Socialization             Reading/ Letter Writing
Caregiver Companionship    Caregiver Respite
Caregiver Socialization         Complimentary Therapy
Bereavement Volunteer       11th Hour Support

Special talents or training:

Previous Volunteer Experience:

Why do you want to volunteer in a hospice setting?

Have you experienced a recent death?  Yes  No

Availability: Mon. Tues. Wed. Thurs. Fri. Sat. Sun.

Morning  Afternoon  Evening  As Needed

Other:

Please list 2 references:

1. Name:

Relationship:

Phone Number:

2. Name:

Relationship:

Phone Number:

How did you hear about this volunteer opportunity?