Consent signed   ____    ____ 
Yes       No 

Name _________________________________________________

Address _____________________________________________________________________

Telephone No. ___________________                 Date Of Birth   _________________________

Next Of Kin __________________________________________________________________

Address ______________________________________________________________________

Telephone No. Res: _____________________         Work: ______________________

Physician (s) ___________________________          Telephone No: ___________________

                            ___________________________   Telephone No: ___________________

Diagnosis            ______________________________________________________________

                            ______________________________________________________________

Referral By           ______________________________________________________________

                            _______________________________________________________________

                            _______________________________________________________________

                            _______________________________________________________________

                           ________________________________________________________________

Reasons for the Referral         _______________________________________________________

    ____________________________________________________________________________

   _____________________________________________________________________________

   _____________________________________________________________________________

   _____________________________________________________________________________

Medications              ______________________________________________________________

   _____________________________________________________________________________

   _____________________________________________________________________________

Referral Taken By _______________________________         Date ________________

Name: _____________________________________________           Date: ____________________

Address: __________________________________________________________________________

_________________________________________________________________________________

Telephone :    Res: _______________________                 Work:  ________________________

Occupation: _______________________________________________________________________

Have you any volunteer experience? _____________________________________________________

_________________________________________________________________________________

Hobbies & interests . . . . . . . special skills you would like to share
_________________________________________________________________________________

_________________________________________________________________________________

Please list any courses, workshops etc. related to paliative care:
_________________________________________________________________________________

Have you ever suffered a significant loss ( a close relation or friend) How long ago?
_________________________________________________________________________________

Why do you want to become a Hospice volunteer? __________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Do you have transportation available? ____________________________________________________

_________________________________________________________________________________

What times are you available? __________________________________________________________

_________________________________________________________________________________

Do you speak languages other than English? ________________________________________________

Are you actively involved in your faith community? ___________________________________________

At the end of your initial volunteer training, the Hopsice Coordinator will discuss with you the options for volunteer service. These include client care, committee work, office help, community education, etc. We look forward to working with you.