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

In The News

Hike for Hospice Raises $338,000

Top Youth Fundraiser 2019