Hospice Care of Southwest Michigan Volunteer Application

Centrica Care Navigators Volunteer Application

Formerly Hospice Care of Southwest Michigan
Full Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
E-mail
Address *

Street Address

Apartment no. or P.O. Box

City State / Province

Postal / Zip Code
Name of Municipality (City, Township, Village) *
Please specify whether City, Twp., or Village *
Preferred Phone Number *

Area Code Phone Number
Home Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number

Your current status.

	Full Time Student	Employed	Retired
Employment Status

Education

	Name of the Institution	Your Field of Study	Degree/Certification Earned	Year Completed
1.
2.
3.

Employment History

How did you hear about Centrica Care Navigators? *
Did you receive a letter from Centrica Care Navigators regarding volunteer opportunities? *
Why do you want to be a volunteer with the agency? *
Have you experienced the death of a loved one in the last year? *

Yes No
Tell us something about that experience.
Tell us about previous volunteer experiences.
Do you have any special skills or interests?
Tell us about languages, other than English, that you can speak. *
Have you ever been convicted of a crime *

Yes No
If yes, please explain.
Do you have a valid driver's license? *

Yes No

	Interested	Possibly Interested	Not Interested
Hospice Clients: Work directly with clients receiving hospice services (companionship, respite, light housekeeping, etc) .
Administrative / office support roles.
Journeys Grief Support Program for children and families.
Adult Day Services, serving older adults, adults living with dementia, or other disabilities.
Rose Arbor Hospice Residence.
Glenn Arbor Hospice Residence.
Pet Therapy services with my dog.
I have not decided.

Centrica Care Navigators Volunteer Application