2015 Walk Run for Hospice

Thank you for expressing your interest in becoming a hospice volunteer. The following information is necessary in making our volunteer assignments and in utilizing your talents and skills to the fullest. We ask that all volunteers make a year commitment to working with our agency.

Questions related to age, gender, religious affiliation and marital status are asked only for purposes of identification and matching volunteers with patient/families. However, volunteers are selected without regard given to factors.

Name *

First Last

Email Address *

Home Phone

Cell Phone

Address *

Street Address Address Line 2 City State ZIP Code

Are you over 16? *

Yes
No

Occupation

Employment Status

Full Time
Part Time
Retired
Not Employed

Place of Employment

Have you experienced the loss of a love one in the past year?

Yes
No

Skills & Hobbies *

Check all that apply.

Please specify any others:

How often are available to work as a volunteer? *

Once a week
Several times a week
Once a month
Several times a month
Whenever needed
Seasonally

Why do you want to become an MVHPC volunteer? *

How did you hear about our MVHPC volunteer program? *

Have you been a volunteer before? If so, where? *

Do you drive?

Yes
No

Are you willing to provide transportation?

Yes
No

Professional References

Please list names, addresses, relationships, occupations, and phone numbers of people we may contact (with your permission) for personal reference. No family, please.

Signature of Applicant *

Please type your name.

Date *

MVH is an equal opportunity employer. The socio-demographic information we are collecting is for compatible patient matches only and will not be used or shared for any other reason.

Phone

This field is for validation purposes and should be left unchanged.

Volunteer Application

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