First Name
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Last Name
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Date of Birth (dd/mm/yyyy):
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Phone Number:
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E-mail Address:
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What is the best time and way to reach you?
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Address
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City
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Zip/Postal Code
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Emergency Contact Name:
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Emergency Contact Number:
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Occupation:
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Do you have any medical limitations that might affect your ability to help others?
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Do you have a valid driver's license?
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Do you have car insurance?
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Do you have regular access to a car?
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Are you willing to drive clients to appointments?
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When are you able to volunteer?
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How many hours a week would you like to volunteer?
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Do you speak and/or write any languages other than English? Which languages?
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Please list any special interests, hobbies, training, or skills that you possess:
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Please specify any previous or present volunteer positions:
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In which capacity would you like to volunteer?
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Preference of Client to work with:
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Do you have any other preferences (ie. non-smoker)
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Why do you want to be a volunteer with Hospice?
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What do you view as the strengths you bring to this work?
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Have you had any experience with death, dying, palliative care, or terminal illness? If yes, please explain briefly:
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What did you learn from this experience?
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Are you willing to complete our official training program and commit to ongoing educational opportunities?
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Please list the names and addresses of two references. References can be a friend, colleague, neighbour, clergy, etc.
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