Application Form

Personal Information

Name *
City *
Address *
Postal Code *
Phone *
Secondary Phone
Email *
Preferred contact method
How did you hear about us?
How do you prefer to be addressed (preferred pronoun)?

Other Information

What motivated you to volunteer with us? *
What do you hope to gain by volunteering? *
Do you speak any other languages than English fluently? If so, what other languages do you speak? *
Have you spent time with someone very ill or dying? If yes, how long ago? *
Have you experienced a loss through death of someone close to you? If yes, how long ago? *

Work or volunteer experience

What is your main field of study or occupation? *
What is your work and/or volunteer experience? *
Have you had fundraising/special event experience? *
If yes, please describe your experience:

Committing time to Prairie Hospice Society

Are you willing and able to commit to volunteering for one year or more? *
Are you willing and able to commit to volunteering approx. 4 hours per week? *
Are you able to attend the mandatory training program? (approx. 20 hours) *
Do you have any long vacations/absences planned? *
Are you typically away for extended periods at a time? *
If yes, please provide the dates


General Availability: Please describe your availability to volunteer below.

Are you available weekdays during the day? (Preferred by most clients.) If yes, when are you available? *
Are you available evenings? If yes, when are you available? *
Are you available weekends? If yes, when are you available? *

Volunteer Preferences

(check those that apply)

Client Service Volunteer Work:
Other Volunteer Work you would have an interest in at Prairie Hospice Society:
Other general interest – Please specify


Do you have a valid Driver’s License? *
Would you be willing to provide transportation for clients? *


Do you have any physical restrictions that would affect your volunteering? (e.g. back problems, sitting or walking difficulties, allergies, sight/hearing problems) If yes, please specify. *
Do you have pets? (Some of our clients are allergic to animals.) *
If yes, what pets do you have?
Do you have any concerns about volunteering? Please check them off below: *
Other (specify)
Do you have any apprehensions about working with individuals who have a different background than yours? *
Any other groups of concern. Please specify:


Do you have a preference about the age or sex of the client you will be matched with? *
If yes, please describe
Prefer working with: *


Check off any skills or hobbies, activities or interests you will be able to share in the volunteer role. This will help us in matching you to an appropriate client.
Other, please specify:

Emergency Contact Information

Person to contact in case of an emergency: *
Relationship: *
Telephone: *


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/counselor.

Reference #1

Best time to reach

Reference #2

Best time to reach