Hospice Vaughan Application Form
First Name:
Last Name:
Date of Birth (dd/mm/yyyy):
Phone Number:
E-mail Address:
What is the best time and way to reach you? (i.e. 3 pm, phone)
Address Line 1:
Address Line 2:
City:
Postal Code:
Emergency Contact Name:
Emergency Contact Number:
Occupation:
Employed
Retired
Student
Other
Do you have any medical limitations that might affect your ability to help others?
Do you have a valid driver's license?
Yes
No
Do you have car insurance?
Yes
No
Do you have regular access to a car?
Yes
No
Are you willing to drive clients to appointments?
Yes
No
When are you able to volunteer? (select all that apply)
Mornings
Afternoons
Weekends
Flexible Anytime
How many hours a week would you like to volunteer?
Do you speak and/or write any languages other than English? Which languages?
Please list any special interests, hobbies, training, or skills that you possess:
Please specify any previous or present volunteer positions:
In which capacity would you like to volunteer? (Please check all that apply)
In-home Visiting
Office Support
Marketing and Fundraising
Caring Hands Day Program
Children's After School Homework Club
Occasional Skill Sharing (ie. Cooking class, craft once a month, etc.)
Complementary Therapy
Support and Bereavement Mentoring
Support and Bereavement Group Facilitator
Team Leader
Special Events
Preference of Client to work with:
Male
Female
Do you have any other preferences (ie. non-smoker)
Why do you want to be a volunteer with Hospice?
What do you view as the strengths you bring to this work?
Have you had any experience with death, dying, palliative care, or terminal illness? If yes, please explain briefly:
What did you learn from this experience?
Are you willing to complete our official training program and commit to ongoing educational opportunities?
Yes
No
Please list the names and addresses of two references. References can be a friend, colleague, neighbour, clergy, etc.
1) Name/Address/Telephone Number/Email/Relationship/Years you have known reference: 2) Name/Address/Telephone Number/Email/Relationship/Years you have known reference:
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