Stedman Community Hospice

Name:

Date:

Home Phone:

Work Phone:

Please Check:

Volunteer

High School Student (40 Hrs)

Co-op Student

Teen Volunteer

Address:

Postal Code:

Email:

Allergies or Medical conditions:

In case of emergency call:

Emergency Phone:

Also in case of emergency please include health card #:

Occupation:

Fields of Study:

Do you have language skills other than English?

Spoken:

Written:

Volunteer Experiences: Dates: Description of Work:

Professional and Community Affiliations:

Experiences and Skills: arts and crafts, music, hobbies, gardening. Would you be willing to share these in hospice programs (day program/widows sessions)? :

What are your personal goals in becoming a Hospice volunteer?:

Has someone close to you died recently? If yes, please explain how you are dealing with this loss.:

Your Volunteer Interests (SELECT AS MANY AS YOU LIKE):

Reception – handling phones and greeting patients, families and visitors

Residence – preparing residents’ meals, assisting staff

Errands, deliveries using your car

Public Relations Activities e.g. fundraising events, displays, tours

Household duties – cooking, dishes, laundry, light housework,

Gardening, outdoor work

Available Time for Volunteer Work: :

Morning (9-1)

Afternoon (1-5)

Evening (5-9)

Days of the week:

Would you be willing to do an occasional weekend shift?:

Yes

Reference Name:

Reference Phone:

Reference Name:

Reference Phone:

I give St. Joseph’s Lifecare Foundation permission to contact me via email regarding updates and activities (you may opt out at any time).

Stedman Community Hospice

Volunteer Application

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