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

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* 2. Address

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* 3. Birthdate

Date

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* 4. Emergency Contact Information

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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?

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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)

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

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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)

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