Volunteer Application

Personal Profile: Last Name: First Name: Middle: Telephone: Address: City: State: Zip Code: Business Address: Bus. Phone: Business City: State: Zip Code: Education/Field of Study/Degree: Foreign Languages Spoken: Interests/Hobbies/Skills: Organizations to which you belong: Previous Work Experience: Previous Volunteer Experience: Why do you wish to become a Hospice Volunteer?:

Availability When are you available ? (please check off availability) Sunday Monday Tuesday Wednesday Thursday Friday Saturday Morning Afternoon Evening What type of volunteer work interests you?: Direct service: patient support services, companionship, share hobbies/interests, assist with errands Indirect service (check one or both) Clerical Office Special Projects What geographic area(s) would you like to be assigned? (check all that apply) Basking Ridge Bernardsville Bound Brook Branchburg Bridgewater Cranbury Dunellen East Brunswick Franklin Township Green Brook Hillsborough Manville Neshanic Station New Brunswick Piscataway Raritan Rocky Hill Skillman Somerset Somerville South Bound Brook Warren Zarapath Do you have transportation available? Yes No What is the name of your auto insurance company?

Health Describe your physical health in the past year: Describe your emotional status in the past year: Are you willing to have a physical examination? Yes No Do you have any physical limitations that may affect your volunteer placement? Yes No If yes, please explain: Have you experienced the loss of someone close to you within the past year? Yes No If yes, please specify your relationship to the person and when they died: When did you hear about Community Care Hospice?

Personal References: Full Name Telephone# Relationship

Emergency Information: Full Name Telephone# Relationship

By checking this box I understand that in order to become a Community Care Hospice volunteer, I will be expected to participate in a designated Instruction Course (20 hours).