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