NorthBay Hospice & Bereavement Volunteer Application Form

Please complete this application form if you are interested in becoming a volunteer with NorthBay Healthcare. Once you complete the form, click the submit button at the bottom.

Applicant Information

First name:

Last name:

Middle name:

Title:

Nickname:

Type:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

* OK to call me here

Work phone:

OK to call me here

Cell phone:

OK to call me here

Email address:

Date of birth:

Age:

Gender:

Marital status:

School:

College:

Emergency Contact

Please provide two names and contact information in case of emergency.

First name:

Last name:

Home phone:

* OK to call here

Relationship:

Availability

Please indicate the days and times you are usually available to volunteer.

Skills and Experience

Skills:

Employer name:

List all relevant skills and experience (including languages spoken):

College Students

All college students must be 18+.

Education:

Field of study/major and professional goals (please include the name of the school):

References

Please include two references. Only one may be personal.

Employer name:

First name:

Last name:

Title:

Home phone:

OK to call here

Cell phone:

OK to call here

Email address:

Relationship:

Hobbies

What do you like to do? This isn't a trick question, we just want to get a better sense of your personality.

List any hobbies or interests you have:

Email Preferences

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email, however will not send you any email you prefer not to receive. Use the checkboxes below to select the kinds of email you would like to receive from us.

What kinds of email would you like to receive?

Electronic newsletters

Recruitment appeals

Create an account

Using our online volunteer manager, you can check your schedule as well as the status of your application. The email you enter above will be used to log in.

Please enter a password that:

Is between 6 and 30 characters long

Password:

Confirm password:

Agreement and Signature

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, missions, or other misrepresentations made by me on this application may result in my immediate dismissal.

I Agree

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