Prospective Volunteer Survey

Name*

Email*

Mailing Address*

City*

StateStateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip*

Home Address*

City*

StateStateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip*

Main Contact Number

Cell Phone*

COVID vaccination required. Can you provide proof of vaccination?YesNo

If you received the Influenza (Flu) vaccine this year, can you provide proof?YesNo

Name*

Email*

Phone*

Name*

Email*

Phone*

Name*

Email*

Phone*

Are you a Veteran?YesNo

Branch

Years Served

Employed:Full TimePart TimeRetired

Type of Work

College Degree

Year Obtained

Computers Skills (check all that apply):
Microsoft OfficeEmailInternetZoom

Skills and Interests (include all fluent languages):

Please give a brief description of any previous volunteering services?

Tell us why you wish to become a Hospice volunteer?

Have you had experiences with death?

Tell us about when you can serve as a Hospice volunteer, when you can begin and what your monthly availability will be – please be specific:

Weekdays

Weekends

Mornings

Afternoons

Additional notes you would like to make about your application:

Select all areas of interest below

Licensed Service Animal: Bring your valid NY licensed pet to homes and facilities.

Veterans to Veterans: Veteran volunteers visit and support Veteran patients.

Music & Memory: Provide music for patients and families.

Bereavement Support: Make comfort phone calls and prepare mailings. Requires basic computer skills.

Alternative Services: NY license in alternative therapy (i.e., massage, reflexology, aromatherapy).

Office Skills: Administrative tasks. reception coverage (part-day or full-day coverage). Typing, copying, assembling packets or mailings, handwriting sympathy cards, etc.

Crafters: Knitting, quilting, sewing, crocheting, arranging flowers, scrapbooking, journaling – calling and meeting with patient and/or caregivers.

Transportation: Transport patients and caregivers to appointments, stores, and outings.

Fundraising/Marketing: Support fundraising and marketing efforts by representing Hospice at various events in the community. Speak with individuals about Hospice services and upcoming events.