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:
Choose
Dr.
Mr.
Mrs.
Ms.
Nickname:
Type:
Choose
Adult Student
Chaplaincy
Hospice
Hospital Volunteer Guild
PAWs
Teen/High School
Trama Intervention Volunteer
*
Street 1:
*
Street 2:
City:
*
State:
Choose
AZ
CA
IN
*
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:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
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Year
2023
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1918
*
Age:
Gender:
Choose
Decline to State
Female
Male
Non-binary
Other
Marital status:
Choose
Married
Single
Widow/widower
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:
Choose
Co-worker
Daughter
Father
Friend
Mother
Neighbor
Son
Spouse
Supervisor
Availability
Please indicate the days and times you are usually available to volunteer.
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Morning:
Afternoon:
Evening:
My availability is:
Choose
Ongoing
Ongoing, except between these dates
Only between these dates
From:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
to:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
I would like to serve up to:
hours:
Choose
Daily
Monthly
One time
Weekly
*
Assignment Preference:
Bereavement Care [Hospice]
Bereavement Office Assistance [Hospice]
Fundraising [Hospice]
Patient Care - Home Visits [Hospice]
List the area you'd like to work in (Gift Shop, Thrift Shop, Mother Baby, etc.):
Skills and Experience
Skills:
Gardner
Knit/Crochet
Piano Player
Sewing
Singer
Woodworking
Employer name:
List all relevant skills and experience (including languages spoken):
College Students
All college students must be 18+.
Education:
Choose
Associate degree
Bachelor's degree
Doctoral degree
High school
Masters degree
Some college
Trade/Vocational school
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:
Choose
Dr.
Mr.
Mrs.
Ms.
Home phone:
OK to call here
Cell phone:
OK to call here
Email address:
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Mother
Neighbor
Son
Spouse
Supervisor
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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