SILVERADO HOSPICE

VOLUNTEER APPLICATION

Thank you for your interest in becoming a hospice volunteer. Please complete both sides of this application
and return it to the address listed.

Name (Last, First, MI) AGE: 0-10__ 10-16__ 16-18__ over 18____
Birthday (Mo/Day)
____________________________________
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Address Home Phone #

____________________________________
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City, State, Zip Code Pager/Cell Phone #

Email address_________________________

Employer Work Phone #

____________________________________
________________________

Occupation Working Hours

____________________________________
________________________

Brief description of the work you do:

Total number of hours per week you could be available for hospice volunteering:

Daytime:_______ Evenings:_______ Weekends:_______ Other:_______

Level of Education: High School 2 Yr College Four Yr College Post Graduate

Foreign languages spoken:__________________________________________________

Religious Affiliation:

(Optional—this assists us in proper placement of our volunteers. We serve patients regardless of religious
affiliation.)

Catholic Protestant Jewish None Other___________________

Personal Information:

How did you hear about us? ________________________________________________

Do you need volunteer hours? _____ If so, how many?___________

Why do you wish to be involved in hospice?

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
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What organizations or clubs do you belong to?
_______________________________________________________________________
_

Have you had experience with the terminally ill?________________________________

_______________________________________________________________________

Emergency contact

By returning this application you are promising to hold Silverado harmless of any
liability. Accept___ Decline___