Volunteer Application
Email
example@example.com
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Birthday (year optional)
Email
example@example.com
When are you available? Please includes days of the week and morning, afternoon or evening hours.
Best way to contact you & best time of day:
Are you willing to travel to surrounding communities?
Yes
No
If yes, how far from your home are you willing to travel? (Mileage reimbursement is available upon request)
What type of service would you like to provide to patients and families?
Patient/family support
Running errands
Relief to caregiver(s)
Light house cleaning
Yard work
Office help
Providing bars/cookies
Delivering or picking equipment up from patients homes
Bereavement
Help at Our House with homemaker services
Provide overnight relief for caregiver(s)
Are you willing to sit with patient during final hours
Meal preparation
Mailings
Meal shopping
Assist at Our House (Hospice House)
Grocery shopping Tuesdays & Fridays (list made by house supervisor)
Meals (Noon hour approximately 11:00a-1:00p)
Baking weekdays AM or PM
Yard work
Do you have special skills or licensure such as HHA/RN/LPN/CNA? If so, please indicate.
Is there a time of year you cannot volunteer?
Yes
No
If so, when?
Would you be interested in helping with:
Spring Auction (April)
Rummage Sale (September)
Tree of Lights (November/December)
If interested in helping with the Tree of Lights, which town?
Submit
Should be Empty: