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Volunteer Application.doc - Hospice San Miguel de Allende

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					                     HOSPICE SAN MIGUEL A.C.
                                    CUIDADOS PALIATIVOS

                            VOLUNTEER APPLICATION
    (PLEASE COMPLETE AND RETURN TO LOCATION WHERE YOU RECEIVED THIS FORM)

Name:                                                                Birth Date:

Address:

City:                                         State:                  Zip/CP:

Home Phone: (           )                     Work Phone: (          )

Other: (        )                             Email:

Emergency Contact:                                            Relationship:

Contact Phones: (           )                          Work/Other: (             )

Contact Address:


1. What are you interested in doing as a Hospice Volunteer? Please check the following:

 Patient Visits       Family Visits          Fundraising           Publicity      Office

 Spiritual            Bereavement            Transportation        Other:

Comments:




2. What do you hope to gain from your volunteer experience?




_____________________________________________________________________________________
                                                                                    1
  Calle Manuel Rocha # 35, Colonia La Lejona, San Miguel de Allende, Guanajuato, Mexico C.P. 37765
          Tel. 01 52 (415) 154 4287      mail@hospicesma.org          www.hospicesma.org
                     HOSPICE SAN MIGUEL A.C.
                                    CUIDADOS PALIATIVOS
3. Have you experienced a significant loss or stressful circumstances in the past year? If so,
please explain:




4. Please list your education, hobbies and interests:




5. What volunteer experience, including hospice, do you have?




6. List any work experience or training or special skills that you think is related to Hospice:




7. What languages other than English do you speak? If so, what is your degree of fluency?




_____________________________________________________________________________________
                                                                                    2
  Calle Manuel Rocha # 35, Colonia La Lejona, San Miguel de Allende, Guanajuato, Mexico C.P. 37765
          Tel. 01 52 (415) 154 4287      mail@hospicesma.org          www.hospicesma.org
                     HOSPICE SAN MIGUEL A.C.
                                    CUIDADOS PALIATIVOS
8. Do you have any physical or health limitations that should be considered when placing
you in a Volunteer Hospice position? If yes, please explain:




9. Are you willing to transport patients or family members?



10. Do you have auto insurance?



Please mark (X) the days and times below that you are able to volunteer:

TIME/DATE     Sunday      Monday      Tuesday      Wednesday Thursday         Friday      Saturday
Mornings
Afternoons
Evenings

What months are you normally in San Miguel?

Thank you for your interest in Hospice San Miguel!

Volunteer Signature:

Date:


                     PLEASE RETURN THIS COMPLETED FORM
                   TO THE LOCATION WHERE YOU RECEIVED IT!


Revised on May 8, 2008




_____________________________________________________________________________________
                                                                                    3
  Calle Manuel Rocha # 35, Colonia La Lejona, San Miguel de Allende, Guanajuato, Mexico C.P. 37765
          Tel. 01 52 (415) 154 4287      mail@hospicesma.org          www.hospicesma.org

				
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posted:8/6/2011
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