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

In case of emergency, please contact:

Name

Relationship

Phone

Find CareCHOICES

Hospice / Palliative / Foundation
20 Corporate Park Drive
Suite 300
Irvine, CA 92606

Home Health
1501 E Orangethorpe Ave
Suite 220
Fullerton, CA 92831

Contact Us

Hospice / Palliative / Foundation
949.777.8600

Home Health Services
714.515.7650