Name: _____________________________________________           Date: ____________________

Address: __________________________________________________________________________

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Telephone :    Res: _______________________                 Work:  ________________________

Occupation: _______________________________________________________________________

Have you any volunteer experience? _____________________________________________________

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

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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?
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Why do you want to become a Hospice volunteer? __________________________________________

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Do you have transportation available? ____________________________________________________

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What times are you available? __________________________________________________________

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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.