Your Age* Under 18 Over 18 If you are under 18 years of age, a parent or guardian must complete this form.Volunteers must be 14 years of age or older. (Volunteers who are 14-17 years old participate in our Junior Volunteer Program.) All volunteers are required to participate in a certification program to learn about the concept and mission of hospice care. Volunteer InformationName* First, MI Last Nickname Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Home Phone*Cell PhoneWork PhoneAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Emergency Contact Name* First Last Emergency Contact Relationship* Emergency Contact Phone Number*Employment, Education, and Volunteer ExperienceEmployer Name (current or previous)* Occupation/Title* Are you currently employed?* Full Time Part Time Retired N/A High School*Check last grade completed. 9 10 11 12 N/A College*Check number of years completed. 1 2 3 4 N/A College Major Have you previously served as a volunteer?* Yes No If yes, where?*What type of service?*Interests and AvailabilityPlease select the location where you would like to volunteer.* Newark area (New Castle County) Dover area (Kent County) Milford area (Sussex County) Pennsylvania Delaware Hospice Center in Milford Please select interests/preferences.*Please select all that apply. Helping Patient/Caregiver in the Home Helping Patient in Nursing Home Fundraising/Community Events Mailings/Special Projects Filing/Medical Records Computer Skills/Data Entry Errands/Transportation Bereavement Working with Bereaved Children Delaware Hospice Center Please select the days you are most often available to volunteer.* Sunday Monday Tuesday Wednesday Thursday Friday Saturday Please select the times you are most often available to volunteer on Sundays.*Please select all that apply. Morning Afternoon Evening Please select the times you are most often available to volunteer on Mondays.*Please select all that apply. Morning Afternoon Evening Please select the times you are most often available to volunteer on Tuesdays.*Please select all that apply. Morning Afternoon Evening Please select the times you are most often available to volunteer Wednesdays.*Please select all that apply. Morning Afternoon Evening Please select the times you are most often available to volunteer on Thursdays.*Please select all that apply. Morning Afternoon Evening Please select the times you are most often available to volunteer on Fridays.*Please select all that apply. Morning Afternoon Evening Please select the times you are most often available to volunteer on Saturdays.*Please select all that apply. Morning Afternoon Evening Skills and ExperienceClerical Skills Typing Filing Computer Skills Medical Records Mailings Data Entry Using Copier Communication Skills Public Speaking Journalism Photography Graphic Art Calligraphy Public Relations Please list any foreign language(s) that you speak.Please list any skills/hobbies that you use or teach.(such as baking, sports, hair styling/cutting, crafts, musical instruments, etc.)Military ExperienceReason for volunteering with Delaware Hospice*How did you hear about volunteer opportunities with Delaware Hospice?*Personal ReferencePersonal Reference Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Relationship* Photographic/Testimonial ReleaseBy becoming a Delaware Hospice Volunteer, I hereby assign all rights to the film/ photography/ videotape/ sound recordings/ testimonials made of or by me for Delaware Hospice, and I hereby authorize the use of same by Delaware Hospice, and those acting with its permission, for the purpose of illustration, publications, or broadcast in connection with the work of Delaware Hospice. I expect no financial remuneration for lending my image or testimonial to the marketing, public relations, or advertising efforts of Delaware Hospice. Photographic/Testimonial Release Untitled
