Volunteer Application Question Title * 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 Question Title * 2. Address Address Address 2 City/Town Province Postal Code Question Title * 3. Birthdate Date / Time Date Question Title * 4. Emergency Contact Information Name of contact Relationship to you Phone (home) Phone (cell) 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? Question Title * 11. Do you have a good support system? How do you practice self-care? Question Title * 12. Do you speak any languages other than English? No Yes (please specify) Question Title * 13. Have you experienced a loss (death, divorce, major life change) in the past year? No Yes (please specify) Question Title * 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.) No Yes (please specify) Question Title * 15. Any environmental concerns (i.e.: allergic to scents, pets, smoke, etc.) No Yes (please specify) Question Title * 16. Are you ok to support a client who smokes (tobacco/cannabis/vaping)? No Yes Comment (optional) Question Title * 17. Are you ok to provide support in a home with pets? No Yes Comment Question Title * 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) Question Title * 19. What is your availability? Flexible hours Only certain set days/times (Please check the appropriate boxes in the table below) Question Title * 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 Question Title * 21. Is there anything else that you would like to share with us? Question Title * 22. Reference #1 (preferably a personal, non-family, reference) Name Relationship Email Question Title * 23. Reference #2 (preferably a professional reference) Name Relationship Email Done