Volunteer Application
Name
First and last name
Address
State
City
Zip code
Home phone
Cell phone
Birthdate
(year optional)
Email
When are you available?
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Morning hours
Afternoon hours
Evening hours
Clear selection
Best way to contact you & best time of day:
Are you willing to travel to surrounding communities?
Clear selection
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?
Assist at Our House (Hospice House:)
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?
Clear selection
If so, when?
Would you be interested in helping with:
If interested in helping with the Tree of Lights, which town?
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