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716-686-8077
Contact Us
Become a Volunteer at Hospice & Palliative Care Buffalo
Name
*
Street Address
*
City, State
*
Zip Code
*
Email Address
*
Telephone: Home
Telephone: Cell
Telephone: Work
Can you receive calls at work?
Yes
No
Current Place of Employment & Position
*
Date of Birth
*
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
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31
Year
1933
1934
1935
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1937
1938
1939
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2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
Emergency Contact
*
Relationship
*
Emergency Contact Phone
*
Emergency Contact Address
*
How did you find out about Hospice Volunteering?
*
Utilized services in the past
Newspaper/TV/Radio ad
Social Media
Website
Word of Mouth
School/Organization Volunteer Hours
School
Grade
School Contact
School Contact Phone
Parent/Guardian
Parent/Guardian Phone
Most schools require a certain amount of volunteer hours for specific courses or graduation. Will you be fulfilling these hours through volunteering with Hospice?
Yes
No
If yes, how many hours do you need?
Do you plan on volunteering after you've completed your hours?
Yes
No
Military Experience: Branch
Dates of military service
Interest and/or Certification
Computer
Home Repairs
Notary
Sewing
Cooking/Baking
House Cleaning
Reading aloud
Yardwork
Hairstylist
Musician
Registered Nurse
Videography/Audio
Are you fluent in a foreign language or American Sign Language?
Other: Please Explain
Time Availability *
*
Weekday Mornings (7am-12pm)
Weekday Afternoons (12pm-5pm)
Weekday Evenings (5pm-9pm)
Weekday Overnight (9pm-7am)
Weekend Mornings (7am-12pm)
Weekend Afternoons (12pm-5pm)
Weekend Evenings (5pm-9pm)
Weekend Overnight (9pm-7am)
Desired Areas of Volunteering
*
Special Events
Administrative
Patient Support/Direct Care
Administrative Services (M-F daytime positions)
Phone receptionist
Greeting campus visitors
Cafe
Baking
Filing
Nurses' station receptionist
Mailings
Gardening
Direct Care/Patient Support
Visit patients in their homes (hospice & pre-hospice)
Visit patients in the inpatient unit (Cheektowaga)
Visit patients in a facility (nursing home/ assisted living /hospital/group home)
Visit bereaved families
Hairdresser (copy of current license required if providing services to patients)
Pet therapy
Phone support
Delivering birthday cakes to patients
Audio recording of patients' stories
Patient/caregiver transportation
Evening & weekend refreshment cart (inpatient unit in Cheektowaga)
Veterans helping veterans
Children's programs
Special Events
Yes
No
Have you experienced the loss of a loved one in the past year? If so, please briefly describe:
Have you been convicted of a crime? *
Yes
No
If yes, please explain:
References
Two references are required of Hospice & Palliative Care Buffalo volunteers. Please note, referances should be professional in nature. Members of your family will not be considered as references regardless of any professional relationship with them. References from work or volunteer assignments are most helpful. Please use full names & provide complete addresses.
Name (1st reference)
*
Street Address
*
City/State
*
Zip
*
Email Address
Phone
*
Position/Relationship to you
*
Name (2nd reference)
*
Street Address
*
City/State
*
Zip Code
*
Email Address
Phone
*
Position/Relationship to you
*
I hereby authorize Hospice & Palliative Buffalo to request of the above individuals' information regarding my appropriateness as a Center for Hospice & Palliative Care volunteer.
*
Sign electronically with your full name.
I grant full permission to Hospice & Palliative Care Buffalo and its affiliates to use photographs of me for print and/or digital promotional purposes.
*
Sign electronically with your full name.