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VOLUNTEER FORM     Personal Information Name Date Address City State Zip Home Phone Work Phone Fax Email Age Group Under 21 21-30 31-50 51-65 Over 65 Currently Employed? Yes No Where? Please note completed education and any degrees held Limitations related to health Contact in case of emergency Relationship Home Phone Work Phone How did you hear about Family Hospice? Have you had volunteer experience? Yes No Previous volunteer experience Indicate hobbies/special interests Average hours a week you would like to volunteer Days/Times available Please give any other information you feel would be pertinent to your application   References (please give two references other than family members) Name Phone Address City State Zip Name Phone Address City State Zip   Interest/Skills (please check any special skills you would be willing to share as a volunteer) Artwork Bookkeeping Typing Word Processing Filing Writing Other Computer Specify   Language Specify Additional Skills/Comments   Please check volunteer activities you are interested in Providing respite services and companionship to hospice patients and families Providing meals/light housekeeping to patients and families Bereavement follow-up with families Regular office volunteering (computer/clerical/telephone support) Assisting with special projects (bulk mailing, etc.) Assisting with fund raising projects Assisting with marketing projects Assisting with public awareness projects (speaking/writing) Volunteering at Family Heirlooms Resale Shop Additional volunteer activities (please specify) Specify
FAMILY HOSPICE & PALLIATIVE CARE • 50 Moffett Street • Pittsburgh PA 15243 Phone: 412-572-8821 • 1-800-513-2148 • Fax: 412-572-8492 Serving 11 Counties in Western Pennsylvania © 2007 Family Hospice & Palliative Care About Us | For Patients & Caregivers | For Healthcare Professionals | Education and Research | Contact Us | News & Events