800-767-4965

Our mission is to enable people to live with dignity and hope while coping with loss and terminal illness.

Please complete the following application or download a copy and submit it to the main office.

Name: *

Phone #1: *

Phone #2:

Address: *

City/State/ZIP/State: *

E-mail: *

Emergency Contact: *

Relationship:

Phone #: *

Your Current Work Schedule: *

Employment Experience: *

Please list experience, dates, and title or description of work for the past five years.

Why do you want to volunteer for Harry Hynes Memorial Hospice?: *

Type(s) of service you prefer (check all that apply): *

Patient/Family Volunteer Support: Are trained to give respite to caregivers, provide transportation, run errands, be a support to someone grieving by making phone calls, in-person visits, etc.

Staff Support Volunteers: Assist by doing simple tasks like filing, assisting with mailings, delivering pharmacy items, etc.

Education Volunteers: Are trained to help at Harry Hynes Memorial Hospice booths, give presentations, provide refreshments for events, etc.

What has been your experience with hospice (as a family member, friend, or volunteer)?: *

Volunteer Experience: *

Please list three references, unrelated to you, that we may contact. Include their mail or email address and phone number: *

Has someone close to you died within the last year?: *

Yes

What has been your experience with life threatening illnesses and/or death?: *

Have you ever been convicted of a felony?: *

Yes

If yes, please explain:

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313 S. Market · Wichita, KS 67202 · 316-265-9441 · 800-767-4965

800-767-4965

Volunteer Application

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