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
In case of emergency, please contact:
Name
Relationship
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