Volunteers

Submitted by HospiceCB on Tue, 10/04/2011 - 18:47

For any questions or concerns regarding this application or the Palliative Care Service, please contact:

Lisa McNeil-Campbell
Palliative Care Volunteer Coordinator
Phone: 567-8160
Cell: 574-1159
email: pcvolunteers@cbdha.nshealth.ca

Name *

Address *

Postal Code

Email *

Occupation

Telephone (H)

Telephone (W)

Birthdate

Month

Day

Year

Emergency Contact

Name of Contact

Relationship

Telephone

What is Palliative Care?

Why do you want to become a Palliative Care Volunteer?

Personal Reasons/To Give Back

Work Experience

Free Time

other

Volunteer Experience

Yes

If yes, please explain

What days of the week would you be available?

Generally, we ask you to make available 4 hours a week to volunteer with patients and families (depending upon what type of volunteer work you are doing).

Availability

	Morning	Afternoon	Evening	All Day
Sunday	Morning	Afternoon	Evening	All Day
Monday	Morning	Afternoon	Evening	All Day
Tuesday	Morning	Afternoon	Evening	All Day
Wednesday	Morning	Afternoon	Evening	All Day
Thursday	Morning	Afternoon	Evening	All Day
Friday	Morning	Afternoon	Evening	All Day
Saturday	Morning	Afternoon	Evening	All Day

Are you available throughout the whole year?

Yes

If “No”, what months/weeks would you not be available?

Do you have your own transportation?

Yes

Occasionally

Has anyone close to you died within the last year?

Yes

Do you have any family members/friends with a serious illness at present?

Yes

If yes, please explain

References

Please list three (3) references whom we may contact. (Please include last employer, previous volunteer reference, as well as a personal or family reference.)

Name

Address

Telephone

Name

Address

Telephone

Name

Address

Telephone

In considering your application for volunteering within Palliative Care, is there anything else you would like us to know?

I give the Cape Breton Regional Palliative Care Service permission to contact the names I have given in order to obtain a reference *

Yes