Volunteer Volunteer Application Date MM slash DD slash YYYY Full Name First Last GenderPronounsAge 18-35 36-54 55+ Civic/Mailing Address Street Address Address Line 2 City/Town Postal Code Telephone (Home)Telephone (Mobile)Email OccupationLast 5 yearsPrevious Volunteer and/or Community WorkHow did you hear about Hospice PEI?Reasons for Volunteering (in brief) and what skills do you have that would be helpful to Hospice?Is there any other information that would be relevant, so that Hospice PEI can support you in your role as a volunteer? i.e. diabetic, seizures, hearing aids, etc.Have you had a recent loss (within the last 2 years)? If yes, please explain.Are you interested in driving assignments with care recipients? Yes No Willing to have an annual flu shot? Yes No Areas of interest (Please check all that apply) Hospice Services General (Events and fundraising) Region Queens East Prince West Prince CAPTCHA Δ Hospice Services Referral Name: First Last Address: Street Address Address Line 2 City Province Postal Code Phone:Email: Region:QueensEast PrinceWest PrinceDiagnosis:Integrated Palliative Care: Yes No Not on Homecare Program: Yes No Approach to Palliative Care: Yes No Self-Referral: Yes No Please explain:CAPTCHA Δ
