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    Hospice Volunteer Application

RE: BECOMING A HOSPICE HURONIA VISITING VOLUNTEER

Hospice Huronia recruits and trains volunteers to provide two main services - Volunteer Visiting and Bereavement Support.

Thank you for your interest in becoming a Hospice volunteer. Volunteers are the backbone of Hospice Huronia. Through them we are able to deliver services to people suffering from a life-threatening illness or bereaved people, free of charge.

People suffering from a life-threatening illness are referred to our organization by a family member, their church, other community organizations etc. Our office then visits the family to do an assessment of their needs. We try to match two volunteers with each client so that one can stand in for the other. Our volunteers visit with a client/family as pre-arranged through the office. The Hospice Huronia Visiting Volunteer usually visits in the home to assist with the unique needs of the individual, mostly to give respite care to the family. Our objective is for the volunteer to establish a supportive relationship with the client and the family. Therefore we try to get involved as early as possible in the person's illness. Although some of our volunteers visit with a client for more than a year, people often get referred only once they have reached the very final stages of their illness and then a volunteer may only have the opportunity to visit for a few weeks. Each volunteer donates time according to his/her own situation/wishes. Some visit for an hour a week, others up to one full day a week. Usually mutually rewarding relationships develop between our volunteers and their clients.

The kind of service delivered by Hospice Huronia requires a very special kind of volunteer. We are looking for people who are compassionate, non-judgmental, understanding and sensitive, able to actively listen to others and to respect their life-choices and privacy. Being a Hospice Huronia Visiting Volunteer can confront you with many emotional and existential issues and we find that people coping best with this huge task are the ones who are at peace with themselves and their own mortality. We value our volunteers and therefore try to provide as many opportunities for support and training as possible.

The process of becoming a Hospice Huronia visiting volunteer:
. Complete and return this application form.
. Our office will then contact you for a pre-course interview.
. Police check - we will provide you with a letter with which you have to visit your local police station to fill out a form.
. Complete the 30 hour Visiting Volunteer Training Session (October & November or April & May)

Unfortunately this process of becoming a Visiting Hospice Volunteer can be viewed as quite demanding, but it is necessary to protect both our potential volunteers and our clients.


Please feel free to contact our office at 549-1034 if you have any concerns or unanswered questions.


Carol Galbraith
Program Director

 

APPLICATION FORM
HOSPICE HURONIA VISITING VOLUNTEER

  Some of these questions may seem unduly personal or private. However, this information will be helpful in making our volunteer assignments beneficial to all. The matching of client and volunteer is easier if we know your interests, likes and dislikes. It will enable us to effectively meet the needs of those seeking our service.

Your privacy is important to us. We do not share your information with any other party.  We may send you a newsletter or information about Hospice Huronia.

 

All fields other then work (w) and cell (c) phone numbers are mandatory.
Last name: First name:
Birthdate: Marital status:
Telephone: (h) (w) (c)
Email:
Address:
Town: Postal:
Dependant(s) &
age(s):
Religion: Languages spoken:
Drivers license:           Car available:           Car insured:
Any health related problems or physical limitations
(for example lifting, pushing wheel chairs, allergies, etc):
PERSON TO NOTIFY IN CASE OF EMERGENCY
Name: Phone number:
Family doctor: Phone number:
EDUCATION EXPERIENCE AND EMPLOYMENT
(You may also email your resume to us.)
Training and education:
Work experience:
Current employment:
Volunteer or community service experience:
Agency: Describe your involvement: How long?:
Special interests, hobbies and skills:
Has someone close to you died recently?
How long ago?
Reason for your interest in volunteering for Hospice:
Please check all the types of volunteer help you are prepared to give:
Sitting with patients.
Sitting with relatives (for example children).
Simple hands-on comfort measures for patients.
Light meal preparation (for example fixing a sandwich for lunch).
Shopping.
Caring for pets.
Transportation of patients.
Transportation of relatives.
Companionship.
Visiting bereaved relatives.
Other:   
Would you be willing to help with any other functions:
Hospice office work.
Fundraising.
Bingo.
Library.
Public speaking.
Other:   
Would you prefer a non-smoking client?
Would you be able to be with a smoking client?
Would you like a regular commitment?
How many hours per week would you be available
What do you prefer? (check all that apply) Mornings. Afternoons. Evenings. Nights.
IMPORTANT
  • Volunteers are asked to make a 75 hour commitment to Hospice Huronia on completition of the training course.
  • A $50 tax-deductable fee is charged to cover training cost. this is waived depending on the circumstances.
Please type your full name and check box to act as electonic signature.

I confirm my identity.
Date of application:


VOLUNTEER REFERENCE FORM
Instructions:
  • Please do not include family members as references.
  • List their names and contact data below.
  • Sign the release statement below.
PERMISSION FOR THE RELEASE OF INFORMATION

I, give my permission to Hospice Huronia to receive information regarding my suitability to become a "Visiting Volunteer" from the people listed below as personal references. I will be responsible for obtaining a police check from my local police station.

Reference #1:
Name: Relationship:
Telephone: (h) (w) (c)
Address:
Town: Postal:
Reference #2:
Name: Relationship:
Telephone: (h) (w) (c)
Address:
Town: Postal:

CONFIRMATION OF INFORMATION

By completing the information below, you are confirming that
the information provided by you is accurate.
Please type your full name and check box to act as electonic signature.


I confirm my identity and the accuracy of
the information I've provided.
Date of application:

You may wish to print a copy of this form for
your own records before you press the submit button.

 

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