Become a Volunteer

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (home)

Phone (cel)

Email*

Enter Email Confirm Email

Emergency contact information (Primary)

Name

First Last

Relationship

Home #

Work #

Cel #

Emergency contact information (Secondary)

Name

First Last

Relationship

Home #

Work #

Cel #

May we contact you at work?

Yes
No

Voluteer Opportunities

Please feel free to check of more than one if you wish.

Work Experience and Education

Do you have volunteer experience?

Yes
No

If yes, where and in what capacity?

Please describe your education, skills and abilities that may be beneficial to our organization.

Language and Culture

Do you speak, write or read in any languages other than English?

Yes
No

Language spoken 1

Language ability_1

Speak
Read
Write

Language spoken 2

Language ability_2

Speak
Read
Write

Reason for Volunteering

Why would you like to volunteer for Maison McCullochHospice?

How did you learn about volunteering at Maison McCulloch Hospice?

Background Information

Have you had experience with the terminally ill?

Yes
No

Have you had a person close to you die within the last year?

Yes
No

Relationship

Do you have any allergies?

Yes
No

If yes, to what?

What is your availability?

Monday

Morning
Afternoon
Evening

Tuesday

Morning
Afternoon
Evening

Wednesday

Morning
Afternoon
Evening

Thursday

Morning
Afternoon
Evening

Friday

Morning
Afternoon
Evening

Saturday

Morning
Afternoon
Evening

Sunday

Morning
Afternoon
Evening

References

Please provide two references other than family.

Name 1

Nature of relationship 1

Email 1*

Phone 1

Name 2

Email 2*

Phone 2

Nature of relationship 2

To maintain the integrity of our hospice and for the protection of our residents, a screening process will include an interview, contacting your two references and a criminal reference check.