Name:_________________________________________________________
                  Last                                              First

Address:________________________________________APT.____________

City:_____________________Province:___________Postal Code:_________

Home Phone:(   )__________________Business:(   )____________________

Fax:(   )___________________Other: _______________________________ email:_____________________________

May we contact you at work?   Yes           No

Experience in Hospice tells us that certain issues turn out to be important for volunteers working with dying people.  Please read the following questions and write your responses in the indicated space.

1. How did you become interested in our Hospice and what makes you want to volunteer in this setting?

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2. Is there an area in which you would like to work or in which you have special expertise?

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3. Do you have any concerns or questions about working with our Hospice?

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4. Sometimes volunteering can be very demanding and we are concerned that you have others to support you outside of our Hospice.  Briefly describe your personal supports and how you deal with stress.

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5. Have you experienced any losses( i.e. bereavement, job, close relationship) within the past 18 months?

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6. Would you please indicate the days and hours you will be available.

7. Is there anything you would like to add to the above?

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8. Please give two volunteer or professional references (not including family)

Name_______________________Phone_________________Relationship____________________

Name_______________________Phone_________________Relationship____________________

To maintain the integrity of our hospice and for the protection of our residents, a screening process will include an interview, contacting your two references and may include a criminal reference check.

Date_______________________Signature____________________________________

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