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)? he/him she/her they/them 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? * Yes No 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? * Yes No Are you willing and able to commit to volunteering approx. 4 hours per week? * Yes No Are you able to attend the mandatory training program? (approx. 20 hours) * Yes No Do you have any long vacations/absences planned? * Yes No Are you typically away for extended periods at a time? * Yes No If yes, please provide the dates Availability 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: Companionship (direct one on one client match) e.g. visiting, sharing activities, light chores, errands, accompanying to appointments, outings etc.) Practical support for a variety of clients e.g. rides, grocery shopping, medication pickup Respite relief care (caregiver support) Rides for clients/family members Other Volunteer Work you would have an interest in at Prairie Hospice Society: Office/computer work Fundraising/ Special Events Communications (newsletter, website, brochures, promotional) Committee/Board Work Other general interest – Please specify Transportation Do you have a valid Driver’s License? * Yes No Would you be willing to provide transportation for clients? * Yes No Restrictions 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.) * Yes No If yes, what pets do you have? Do you have any concerns about volunteering? Please check them off below: * Difficulty with driving at night Aversions to smells or body fluids Smoking Fear of animals Poor housekeeping No concerns Other (specify) Do you have any apprehensions about working with individuals who have a different background than yours? * Intellectual disabilities (e.g. dementia, Alzheimer’s disease, etc.) Ethnic origin Sexual orientation Addictions No apprehensions Any other groups of concern. Please specify: Preferences Do you have a preference about the age or sex of the client you will be matched with? * No preferences, willing to work with all ages (i.e. children) and genders Yes – please describe If yes, please describe Prefer working with: * Female clients Male clients No preference Skills/Interests 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. Photography Sewing, Needlework Gardening Sports Walking Genealogy Playing board games, cards, etc. Farming background Artistic (visual and/or performing arts – dancing, musician, singing, artist, doing crafts, acting) Other, please specify: Emergency Contact Information Person to contact in case of an emergency: * Relationship: * Telephone: * References 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 Name Relationship Phone Best time to reach Email Reference #2 Name Relationship Phone Best time to reach Email Submit
