VOLUNTEER REGISTRATION APPLICATION

Please fill out the following form and mail to:
University Hospice
256 Mason Avenue
Staten Island, NY 10305

Thank you for your interest in the Volunteer Program of University Hospice. Please complete the following questions for our files.

NAME____________________________________DATE______________

ADDRESS____________________________________________________

CITY____________________________ STATE___________ZIP________

DAY TELEPNONE #___________________________________________

EVENING TELEPHONE #_______________________________________

DATE OF BIRTH_______________________________________________

In case of an emergency, please contact:

NAME_______________________________________________________

ADDRESS____________________________________________________

CITY____________________________ STATE___________ZIP________

DAY TELEPNONE #___________________________________________

EVENING TELEPHONE #_______________________________________

RELATIONSHIP_______________________________________________

INTERESTS;

Please check the area that best describes your field of interest.

Home Care visits: ________Brooklyn ___________Staten Island _______Queens

__________a.) Emotional support (e.g., companionship etc.)

__________b.) Respite for families (e.g. providing “time off” for caregivers, etc.)

___________c.) Support for care-givers (e.g. shopping, MD’s appointments, etc)

Nursing Home visits: _________Brooklyn _________Staten Island _________Queens

Staten Island: Brooklyn:

________ Clove Lakes _______ Haym Salomon

________ Eger _______ Shoreview

________ Golden Gate _______ Palm Garden

________New Brighton

________ New Broadview Queens:

________ New Vanderbilt

________ Silver Lake _______ Park

________ Resorts

OFFICE WORK

AVAILABILITY:

_______ Monday

_______ Tuesday

_______ Wednesday

_______ Thursday

_______ Friday

_______ Saturday

_______ Sunday

TRANSPORTATION:

Do you drive?

________ Yes

________ No

Have you experienced the loss of someone close to you within the last 2 years?________

If yes, was the person related to you?_______________________________________

What role did you play in caring for the dying patient/_________________________

(We do encourage prospective volunteers to wait 1 to 2 years until their own grief has been dealt with before volunteering.)

How did you hear about University Hospice and its Volunteer Training Program?

_______________________________________________________________________

________________________________________________________________________

What is your understanding of Hospice Care?

_______________________________________________________________________

________________________________________________________________________

_______________________________________________________________________

What makes you interested in being a University Hospice volunteer?