Palliative Volunteer Application – Burnaby Hospice Society

Application Form

PALLIATIVE VOLUNTEER

Name

Phone Number

Address

Postal Code

Age

Emergency Contact

Relationship

Phone Number

Current responsibilities & commitments

Do you have any physical/health restraints that might affect your volunteer placement? (bad back, hearing, vision). Please specify:

How did you hear about the Burnaby Hospice Society Palliative Care Volunteer Program?

Have you been a volunteer before?

yes no

If “yes”, give brief details

What interests you in becoming a Hospice Palliative Care volunteer at this time?

Scheduling

Preferred Times

Morning Afternoon Evening

What limitations or changes do you foresee in your commitment as a volunteer over the next year?

More About Me:

Special Interests/Skills/Experience:

Recreational Activities/Hobbies

Languages Spoken

Education Background

Work Background

Complementary Therapies

Have you had any losses in the last year such as a move, job change, separation or death? Please elaborate

How do you handle stress and what do you do for personal care?

References:

(Someone who has known you for two years and is aware of your work habits or skills through your volunteer or community work. Academic references are also acceptable).

I agree to abide by the policies and procedures of the Burnaby Hospice Society and to maintain client confidentiality at all times.

*Please note maximum enrolment of the course is limited to 15 participants.

Having trouble with the online form?

If the form above is giving you trouble or you’d rather fill out the form as a PDF, you can download it below.

Please not that this is an alternative method, not an additional step; if you have successfully submitted the form above, do not fill in the PDF.

Please complete the application and forward to:

Palliative Services
Email: volunteers@burnabyhospice.org
Fax: 604-299-7910
Phone: 604-520-5087

Newsletters

Offices & Counselling

4535 Kingsway,
Burnaby, BC V5H 0E5

604.520.5087

info@burnabyhospice.org

Thrift Store

6843 Kingsway
Burnaby, BC, V5E 1E4

604.520.5082

thriftstore@burnabyhospice.org