Volunteer Application Form Name * First Name Last Name Phone (###) ### #### Email * 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 Day Programmes/ workshops Patient Transport Office help Photography/Videography 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 No 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) Thank you! We will be in touch wih you soon.
