Unity Hospice Initial Volunteer Application
Which office?
*
Chicago
Greater St Louis
Indiana
Western IL
Houston
Wisconsin
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Last Name
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Local Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
How did you hear about Unity Hospice
*
Church or Synagogue announcement
Community presentation
Word of mouth
School
Unity Hospice Website
VolunteerMatch
Other
How would you describe your general health in the past year?
*
good
fair
poor
How often would you like to work as a volunteer?
*
once a week
several times a week
once a month
several times a month
Other
Is there anything in the patient's home environment that would prevent you from volunteering?
*
smoking
pets
stairs
Other
Have you experienced any deaths in your family or of those close to you?
*
yes
no
If yes, please specify - include your relationship to the person and when they passed away
Why did you decide to volunteer for hospice?
*
Applicant Signature
*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Getting To Know You
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What led you to become interested in the hospice concept?
*
What kind of experience or familiarity do you have with nursing homes or other forms of assisted living facilities?
*
Do you have any previous experience with terminal illness (either personal or professional?) If so, how did you cope with this death or illness?
*
What languages do you speak?
*
Are you flexible in accepting different life-styles or cultural and religious orientations that may conflict with your own beliefs or values
*
Yes
No
What possible concerns, limitations, or challenges might you have about working with hospice patients?
*
How do you feel about sitting in silence with a patient?
*
What ways can the Volunteer Coordinator support you during your time with Unity?
*
Other comments or questions concerning hospice:
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