First and last name
When are you available?
Best way to contact you & best time of day:
Are you willing to travel to surrounding communities?
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?
Relief to caregiver(s)
Light house cleaning
Delivering or picking equipment up from patients homes
Help at Our House with homemaker services
Provide overnight relief for caregiver(s)
Are you willing to sit with patient during final hours
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
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?
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?
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