Seacoast Hospice

Date:

Primary Area of Interest

Office Services Direct Patient Support

Volunteers are selected based upon application, interview and the needs ofthe organization. Please complete the following application and click submit.

1. Personal Information:

Name:

Street:

City: State: Zip:

Email:

Phone: Home Work Cell

Occupation: D.O.B. (optional):

Please tell us who to contact in case of emergency:

Name:

Phone: Relationship:

Where to Contact:

2. How did you hear about Seacoast Hospice?

3. Why are you interested in volunteering with Seacoast Hospice?

4. Please List any special training, skills, talents, interests, hobbies, etc. that you have. Include any licenses or certifications that might apply.

5. Do you have any medial or physical limitation that would interfere with your ability to perform volunteer activities? No Yes
If yes please explain:

6. Can you make at least a one-year commitment?

7. Is there anything else you would like us to know at this time?

8. Please provide names, complete addresses and contact information of four (4) references who can speak to your ability to volunteer with Seacoast Hospice. (Please include complete address information as we will contact them by postal mail.)

1.
Name:
Street:
City: State: Zip:
Email:
Phone: Home Work

2.
Name:
Street:
City: State: Zip:
Email:
Phone: Home Work

3.
Name:
Street:
City: State: Zip:
Email:
Phone: Home Work

4.
Name:
Street:
City: State: Zip:
Email:
Phone: Home Work

9. Please describe your most significant personal experience(s) with loss, whether from death, illness, accident, relocation, job or role change, or ending of a relationship. Explain how you have resolved your loss and why you now want to help others with their losses. (If you are applying for office Service Volunteering, you may skip this question if you choose.)

10. Which of the following volunteer activities are you interested in?

Computer / Data Entry	Baking / Cooking	Aromatherapy
Graphic Design	Decorating	Bereavement
Mailings	Gardening	Children's Programs
Notary	Knitting / Crochet	Errands
Video / Photography	Music / Singing	Reiki
Committees	Painting	Spiritual Care
Library	Staff Tables	Vigil
Short Notice Visitations	Speaking	Support Group Facilitator
Fundraising	Special Events

Initial here to give Seacoast Hospice permission to verification the information
submitted in this application and to contact your references: