Volunteer Form Contact Information Full Name: Address: Apt. #: City: Postal Code: Nearest Intersection: Phone: Cell: Email: How did you hear about Heart House Hospice? Personal Profile Do you speak any languages other than English? ---YesNo If YES, please list: Please list the cultures you are familiar with: Employment Status: Full time Part time Not employed Retired Looking for work List relevant skills and experience: List your personal hobbies and interests: Have you ever experienced a significant loss? ---YesNo If yes, when: < 6 months <2 years >2 years Briefly explain the significance of loss: Do you consider yourself to be actively grieving? ---YesNo If YES, please explain: Have you ever cared for a person with life threatening illness? ---YesNo If YES, please describe your experience: Availability When are you available to volunteer? Days Evening Weekends How often are you able to volunteer? Weekly Occasional How long can you commit to volunteering at HHH? < 6 months <1 year >1 year Possible Volunteer Opportunity Please identify the volunteer opportunity you are interested in from the list below. Providing direct support to individuals/families with palliative diagnosis: In Home Visiting Children’s program Complementary therapy Day program Transportation Occasional Volunteer Opportunities Volunteering at fundraising/special events or on a committee (i.e. Gala, Handbags for Hospice, Golf Fore Hospice) Helping at Heart House Hospice Office (i.e. administration, reception, data entry, etc) Interested in being a board or committee member Helping out but I’m not sure which opportunity is right for me