Volunteer Application Form - General

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

Name and Phone number

Do you speak any other language, apart from English (please state)?

What personal qualities make you suitable for Hospice work?

If you have previous experience in volunteer work, please describe where and what you did?

Are there other interests and skills you could bring to the Hospice?

What are your reasons for wanting to volunteer for Hospice Wairarapa?

Have you experienced a personal bereavement, and when did this happen?

What type of work would you like to do for the Hospice? (Please tick all appropriate)

Care Companion

Biography writing

Patient Therapy/Support

Cooking

Gardening

Fundraising

Do you have any medical conditions that may affect your ability to carry out Voluntary Hospice Duties?

Please indicate number of hours per week/month that you can volunteer.

Do you have any criminal convictions?

Yes

If you answered yes, what was the offence and when did it occur?

All patient contact roles with Hospice Wairarapa Community Trust require a Police check. Applicants are requested to sign a consent form for Police vetting at the initial interview. All information received from the New Zealand Police is stored confidentially. By signing the Volunteer Agreement, you agree to notify Hospice Wairarapa if you are ever convicted of a criminal offence.

References

Could you please supply the name and contact details of one personal referee who you know will be happy to support your application to become a Volunteer (note that your referee should not be a close relative or a close friend)

First Name

Last Name

Phone

(###)

###

####

Organisation Name:

Name

First Name

Last Name

I agree,

Signature (name)