Palliative Volunteer Application – Burnaby Hospice Society

Application Form

PALLIATIVE VOLUNTEER

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

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.

Application Form: PALLIATIVE VOLUNTEER
*Please note maximum enrolment of the course is limited to 15 participants.

Please complete the application and forward to:

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

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.

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