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Volunteers
A division of
Contact Details
*First Name:
*Last Name:
*Church:
*Address:
*City:
*State/Region:
*Zip/Postal Code:
*Email Address:
*Phone Number:
Work Phone Number:
Cell Phone Number:
Information
Do we have your permission to contact you at your work number? Yes No
Education and work experience summary:
Present Occupation
Place of Employment
FT PT
Please indicate any special interests or hobbies that you have.
Indicate the services you are NOT interested in providing at Affinity-Hospice of Life:
Direct Work with Patients/Families
Clerical Office Help
Public Relations
Bereavement Follow-Up
Special Events
Days/Times Availability
Preferred number of hours per week
How long do you feel that you will be an active hospice volunteer?
Do you have a preference?
Non-smoking
Smoking environment okay
No dogs
Dogs okay
No cats
Cats okay
May we assign you to work with both male and female patients? Yes No
If no, please indicate preferred patient gender? Male Female
Why do you want to become involved with the Hospice volunteer program?
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