Hospice Toronto

RESIDENTIAL & IN-HOMEHOSPICE 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.

Select preferred role(s). Check all that apply:

___Residential‘Hospice for Homeless’ Volunteer ___ In-home Hospice Volunteer

--- Choose One ---Mr.Mrs.Ms.MissDr.Rev / First: / Last:
Address:
City: / Postal Code:
Closest Intersection:
Home Phone: / Work Phone:
Cell Phone: / Other Phone:
E-mail: / ApproxAgeRange: / --- Choose One ---18-2020-3030-4040-5050-6060-7070-8080-9090-100100+
Primary Contact Method: / --- Choose One ---Postal MailE-mailHome PhoneWork PhoneCell Phone
How did you hear about us? / --- Choose One ---Community Volunteer OrganizationFundraiserInternalNewspaperOtherOther HospiceWebsite
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? / --- Choose One ---YesNo
Person to contact in case of an emergency:
Telephone:
What allergies (if any) do you have?
Are you a smoker? / --- Choose One ---YesNo
If yes, how long can you go without a cigarette?

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 dedicated schedule)

Sun / Mon / Tue / Wed / Thu / Fri / Sat
9am-Noon
Noon-3pm
3pm-6pm
6pm-9pm
Comments Re: Availability:

Are you able to make a commitment of a minimum of one year to volunteering with Hospice Toronto?

What languages other than English do you write and/or speak with ease?
Are you willing to serve in a setting with smokers? / --- Choose One ---YesNo
Are you willing to serve in a setting with pets? / --- Choose One ---Yes, but no dogsYes, but no catsYes, all petsNo cats or dogsNo pets
Do you have an interest in supporting our community hospice clients who are experiencing homelessness or who are vulnerably housed? /
--- Choose One ---YesNo
Are you willing to serve in a residential hospice setting where clients may be coping with addiction and mental illness in addition to a life-threatening illness? /
--- Choose One ---YesNo
Are you interested in supporting fundraising events in the community? /
--- Choose One ---Yes, but no dogsYes, but no catsYes, all petsNo cats or dogsNo pets
Do you have an interest in working with children: / --- Choose One ---YesNo
If yes, what experience do you have being or working with children?
Describe the skills or interests you would be able to share with hospice clients and/or their caregivers:
Is there anything else you would like us to consider when matching you witha suitable volunteer role?

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:

Signature: ______

Date: