HOPE HOSPICE
VOLUNTEER APPLICATION
29826 Haun Road, Suite 108, Sun City, CA 92586
Phone: 951.679.8872 FAX: 951.679.7882
Thank you for your interest in becoming a hospice volunteer. Please complete both sides of this application and return it to the address listed.
Name (Last, First, MI)
Are you over 18 years old?
Yes
No
DOB (Month/Day)
Address:
Home Phone:
City, St, Zip:
Cell/Pager:
Employer:
Work Phone:
Occupation:
Working Hours:
Email Address:
Briefly describe the type of work you do:
Total number of hours per week you could be available for hospice volunteering:
Daytime:
Evenings:
Weekends:
Other:
Level of Education:
High School
2 Year College
4 Year College
Post Graduate
Foreign languages spoken:
RELIGIOUS AFFILIATION (optional -- this assists us in proper placement of our volunteers. We serve patients regardless of religious affiliation)
Catholic
Protestant
Jewish
None
Other
PERSONAL INFORMATION
How did you hear about us?
Why do you wish to be involved in hospice?
What organizations or clubs do you belong to?
Have you had any experience with the terminally ill?
Yes
No
Has someone close to you died within the past year?
Yes
No
What do you like about yourself?
Yes
No
Do you have available transportation for your volunteer work?
Do you have a valid California driver's license?
Do you have automobile liability insurance?
(Auto insurance is required if you use your car for hospice work)
Have you been convicted of a felony within the last 7 years?
(Conviction will not necessarily disqualify you from volunteering)
List experiences you believe would be helpful to you in hospice volunteering, i.e., schooling, work, volunteer experience, office skills, arts and crafts, etc.
AREAS OF INTEREST:
(Please check areas of interest)
Direct:
Patient and/or family visits
Meal preparation
Shopping/run errands
Relieve primary caregiver
Read to patient
Homemaking chores
Transportation
Write letters
Child care
Bereavement follow-up
Indirect:
Speakers bureau
Sewing/crafts
Computer work
Office assistance
Videotaping
Music or entertaining
Mass mailings
Photography
Host/hostess for hospice events
PERSONAL REFERENCES:
Name:
Relationship:
Phone: