The Carpenter HospiceApplication for Volunteer Engagement

Burlington, OntarioMarch 2013

CONTACT INFORMATION
Last Name: / First (Given) Name:
Street Address: Apt# / City/Town:
Province: / Postal Code:
Phone (home): / Cell/Work number:
Email:
*preferred method of contact: ___ phone ___email
GENERAL INFORMATION
How did you hear about The Carpenter Hospice?
Why do you want to volunteer in a palliative care setting?
Have you experienced the loss of someone close to you in the past 5 years?
VOLUNTEER EXPERIENCE
Current Volunteer Role
EMPLOYMENT HISTORY
Present Title & Employer
Past Title & Employer
EDUCATION HISTORY
Highest grade complete, courses, workshops, seminars
GENERAL INTERESTS

Please check volunteer role(s) that are of interest to you:

VOLUNTEER ROLE / DESCRIPTION / SHIFT REQUIREMENT
Administrative* / Support Hospice departments with data entry, library management, telephone and other office duties. Computer experience required. / 2-4 hours per shift
During office hours.
Bereavement* / Support Bereavement Coordinator through scheduled telephone calls, and assistance at support groups. / 2- 4 hour shift per month. Mostly daytime shifts
Companioning* / Visit with residents; read with residents; provide a companion. Must be coupled with another volunteer role and only after 6 months of experience at the hospice. / Sporadic
Development / Provide assistance at our Hike & Gala fundraising events. Variety of different roles available. / Variety
Flowers* / Maintaining the floral arrangements in the Hospice. No flower experience is necessary. / 2-4 hours per week.
Kitchen* / Create a “home like environment” at Hospice by preparing and cooking meals for residents, and snacks for families and visitors
Organizing, tidying kitchen.
Grocery Shopping for meal preparations / Minimum one 3.5 hour shift per week. Standing and lifting required.
Maintenance* / Monthly light-duty maintenance and repairs of interior and exterior of Hospice (Not grounds keeping). / Minimum 2-4 hours per month
Reception*
/ - Creates a positive and welcoming environment for residents, families and visitors of the Hospice
- Answers phones and greets visitors at door
- Accepts donations in person and over the telephone / Minimum one 4 hour shift per week
Resident Care*
/ Support the work of Hospice staff to provide comprehensive and compassionate physical individual care to residents. Only after 3-6 months of in-house volunteer experience / Minimum one 4 hour shift per week
Wellness* / Support the outreach programs offered through wellness. Encourage the participants throughout program; set up and tear down events / One 4 hour shift per week. (Daytime hours)

*Please note these roles require volunteers to complete a 10 week Hospice Training Program prior to volunteering. (33 hours in total).

Availability. Please check off which shifts you would generally be available to volunteer.

Sunday / Monday / Tuesday / Wednesday / Thursday / Friday / Saturday
9am-1pm
1pm-5pm
5pm-9pm

The following information will only be used after you have completed your interview with the Coordinator of Volunteers or have been accepted as a volunteer with The Carpenter Hospice. References cannot be spouses or family members.

REFERENCES
REFERENCE #1:
Name: / Phone Number:
Email: / Relationship to Applicant:
REFERENCE #2:
Name: / Phone Number:
Email: / Relationship to Applicant:

I acknowledge that I have read and understood above document. I acknowledge that all the information provided on this application is true, and I give permission for The Carpenter Hospice to verify the information on this application. I understand I will need to provide a vulnerable sector police check for any in-house volunteer roles at my own expense.

Signature of Applicant: / Date:

For further information please feel free to contact the Coordinator of Volunteers at or (905) 631-9994 x. 20