Main Street Hospice, LLC Volunteer Application
Thank you for your interest in volunteering at Main Street Hospice. Please answer the following questions and submit your responses when you are finished with the application. Once you start the application, you will not be able to save it and resume it at a later date.

Once your application is complete, a member from our staff will be in contact with you. Thank you again!

**This information will be held in the strictest confidence.
Email *
Full Name *
Address *
City *
Zip Code *
How long have you lived in Indiana? *
If less than one (1) year, list previous address.
City
State
Zip Code
Home/Cell Phone *
Work Phone
Date of Birth *
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Please list any physical or emotional limitations. *
When would you be available to volunteer? *
Required
Please list any previous volunteer experience. *
Please describe any skills, backgrounds, interest, hobbies, experiences and/or training you would like us to know about. Include any foreign languages you can speak. *
Have you ever been diagnosed with a life threatening illness? *
If yes, please explain.
Where did you hear about Hospice? *
Do you know about the Hospice concept and philosophy? *
Any recent losses? *
What helped you cope with the loss?
What kind of support system do you have in place for you? *
What are some of your personal strengths? What do you see yourself personally adding to the Hospice program? *
What are some of your personal weaknesses? What kinds of things work for you? *
Why do you want to volunteer at Hospice? *
What are your expectations? *
Can you think of a reason you should not be a Hospice volunteer? *
Do you have your own transportation? *
Geographic area of preference of work? *
Areas of interest: *
Required
Interests *
Specify Times Available *
Mornings
Afternoons
Evenings
On Call
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays
Total hours you prefer to volunteer per week/month. *
References
Please list two references we may contact to get to know you better.
1) Name *
Relationship *
Phone *
Email *
2) Name *
Relationship *
Phone *
Email *
By initialing below you agree that all the information you have provided is accurate and to the best of knowledge.
Date *
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A copy of your responses will be emailed to the address you provided.
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