Volunteer Application

First Name

Last Name

Address

Birthdate

City

State

Zip

Phone

Email

Are you 18 years of age or older?NoYes

Do you speak a language other than English?NoYes
If so, what language(s)?

Have you ever been convicted of a crime?NoYes
If so, for what, when, and where?

How did you hear about the CareCHOICES Volunteer Program?Current EmployerFamilyChurchSchool/CollegeVolunteerMatchFriendCareCHOICES.netOther
If Other, please explain

What type of volunteer services/skills are you interested in providing?Patient Companion VisitsOffice AssistanceBereavement ServicesSewing, CrochetingMusic TherapyArt TherapyPet TherapyMassage/ReikiVideoGraphic DesignOther
If Other, please explain

What are your special skills, abilities, training, experiences, hobbies, and interests?

Preferred day(s) to volunteerSundayMondayTuesdayWednesdayThursdayFridaySaturday

Preferred time to volunteerMorningAfternoonEvening

Have you experienced a significant loss in the past year?YesNo

What do you know about Hospice?

Please provide two (2) personal references

Name
Email
Phone
Relationship

Name
Email
Phone
Relationship

In case of emergency, please contact:

Name

Relationship

Phone