Hospice Toronto

HOME HELP VOLUNTEER APPLICATION

Please complete all sections of this form (print or type). This form will remain on file at Hospice Toronto. All volunteer information and files are kept confidential and are only available to authorized hospice staff and volunteers who have signed a

Confidentiality Agreement form.

Return application forms to Hospice Toronto, 2221 Yonge Street, Suite 400, Toronto, ON M4SL 2B4 or visit our website for on-line applications at www.hospicetoronto.ca

Role Preference(s):

Shopping / Homemaking / Cooking
Do you have a current Food Handler Certificate? (Circle) / Yes / No
Salutation: / First: / Last:
Address:
City: / Postal Code:
Closest Intersection:
Home Phone: / Work Phone:
Cell Phone:
E-mail:
Approximate Age Range:
(optional) / 18-20 / 20-30 / 30-40 / 40-50 / 50-60 / 60-70 / 70-80 / 80+
Primary Contact Method:
(Circle One) / Postal Mail / E-mail / Work Phone / Cell Phone / Home Phone
How did you hear about us?
What has motivated you to volunteer with Hospice Toronto at this time?
Previous Volunteer Experience:
Education or Field of Study:
Occupation:
Employer:
May we contact you at work? (Circle One) / Yes / No
Person to contact in case of an emergency:
Telephone:
Are you a smoker? (Circle One) / Yes / No
If yes, how long can you go without a cigarette?
What languages other than English do you write and/or speak?
Are you willing to serve in a home with smokers? (Circle one) / Yes / No
Are you willing to serve in a home with pets? (Circle all that apply) / Yes / No / No Dogs / No Cats
What allergies do you have if any?
Describe any skills that you would be able to share in relation to the volunteer role(s) that you are interested in:
Is there anything else you would like us to consider when matching you with a client?
Availability for Volunteering: (Please check all that apply. Note that the more times you are able to be available the faster we will be able to match you with a client.) Shifts may be between 2 and four hours pending client need and availability for a minimum commitment of one year.
Sun / Mon / Tue / Wed / Thu / Fri / Sat
9am-Noon
Noon-3pm
3pm-6pm
6pm-9pm
Comments Re: Availability: ______

Personal References: (Friend, Volunteer or Work related)

These individuals must be over 20 years of age, should have known you for more than 2 years and may not be a partner, spouse, family member or your therapist/social worker.

Reference #1

Relationship: / Name:
Telephone:
Best time to reach: / E-mail:

Reference #2

Relationship: / Name:
Telephone:
Best time to reach: / E-mail:
Your Signature: / Date: