Volunteer Application Survey

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* 1. Name & Contact Information (note: middle name required for CPIC application letter)

First Name

Middle Name(s)

Last Name

Phone (home)

Phone (Cell)

Email address

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* 2. Address

Address

Address 2

City/Town

Province

Postal Code

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* 3. Birthdate

Date / Time

Date

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* 4. Emergency Contact Information

Name of contact

Relationship to you

Phone (home)

Phone (cell)

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* 5. Describe your previous volunteer or related experience

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* 6. What are some of your hobbies and interests?

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* 7. What words do people usually use to describe you?

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* 8. Why have you chosen to volunteer for Hospice L&A?

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* 9. Describe a time when you turned to someone for help or support. Did you find it difficult to ask for help? What did you feel was most helpful to you in that situation?

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* 10. What kinds of experiences (while working with dying or grieving people) do you think would most likely be most difficult for you?

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* 11. Do you have a good support system? How do you practice self-care?

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* 12. Do you speak any languages other than English?

Yes (please specify)

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* 13. Have you experienced a loss (death, divorce, major life change) in the past year?

Yes (please specify)

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* 14. Do you have any physical limitations that need to be taken into account when being matched with a client (mobility challenges: i.e.: unable to navigate stairs, unable to do light lifting, etc.)

Yes (please specify)

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* 15. Any environmental concerns (i.e.: allergic to scents, pets, smoke, etc.)

Yes (please specify)

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* 16. Are you ok to support a client who smokes (tobacco/cannabis/vaping)?

Yes

Comment (optional)

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* 17. Are you ok to provide support in a home with pets?

Yes

Comment

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* 18. What geographical areas are you willing to provide support

Town of Greater Napanee

Sandhurst Shore/Adolphustown

Hay Bay

Amherst Island

Bath

Amherstview

Odessa

Newburgh/Camden East

Yarker

Enterprise/Centerville/Moscow

Tamworth/Erinsville

Roblin/Westplain/Forest Mills

Deseronto

Comments (optional)

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* 19. What is your availability?

Flexible hours

Only certain set days/times (Please check the appropriate boxes in the table below)

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* 20. Availability (check all that apply)

	Morning	Afternoon	Evening	Anytime	Not Available
Monday	Monday Morning	Monday Afternoon	Monday Evening	Monday Anytime	Monday Not Available
Tuesday	Tuesday Morning	Tuesday Afternoon	Tuesday Evening	Tuesday Anytime	Tuesday Not Available
Wednesday	Wednesday Morning	Wednesday Afternoon	Wednesday Evening	Wednesday Anytime	Wednesday Not Available
Thursday	Thursday Morning	Thursday Afternoon	Thursday Evening	Thursday Anytime	Thursday Not Available
Friday	Friday Morning	Friday Afternoon	Friday Evening	Friday Anytime	Friday Not Available
Saturday	Saturday Morning	Saturday Afternoon	Saturday Evening	Saturday Anytime	Saturday Not Available
Sunday	Sunday Morning	Sunday Afternoon	Sunday Evening	Sunday Anytime	Sunday Not Available

Volunteer Application

Question Title

* 1. Name & Contact Information (note: middle name required for CPIC application letter)

Question Title

* 2. Address

Question Title

* 3. Birthdate

Question Title

* 4. Emergency Contact Information

Question Title

* 5. Describe your previous volunteer or related experience

Question Title

* 6. What are some of your hobbies and interests?

Question Title

* 7. What words do people usually use to describe you?

Question Title

* 8. Why have you chosen to volunteer for Hospice L&A?

Question Title

* 9. Describe a time when you turned to someone for help or support. Did you find it difficult to ask for help? What did you feel was most helpful to you in that situation?

Question Title

* 10. What kinds of experiences (while working with dying or grieving people) do you think would most likely be most difficult for you?

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* 11. Do you have a good support system? How do you practice self-care?

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* 12. Do you speak any languages other than English?

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* 13. Have you experienced a loss (death, divorce, major life change) in the past year?

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* 14. Do you have any physical limitations that need to be taken into account when being matched with a client (mobility challenges: i.e.: unable to navigate stairs, unable to do light lifting, etc.)

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* 15. Any environmental concerns (i.e.: allergic to scents, pets, smoke, etc.)

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* 16. Are you ok to support a client who smokes (tobacco/cannabis/vaping)?

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* 17. Are you ok to provide support in a home with pets?

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* 18. What geographical areas are you willing to provide support

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* 19. What is your availability?

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* 20. Availability (check all that apply)

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* 21. Is there anything else that you would like to share with us?

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* 22. Reference #1 (preferably a personal, non-family, reference)

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* 23. Reference #2 (preferably a professional reference)