3746 St. Paul Boulevard
Rochester, NY  14617
Tel: 585-467-3524  Fax: 585-266-5324

VOLUNTEER APPLICATION

Name: __________________________ Tel: _____________ Date: _________
Address: _____________________________________   Zip Code: _________
Age (Optional): _________  Retired:  Yes ___ No: ___
Email Address: _______________________________

Are you working, or have you ever worked in a nursing capacity?  Yes ____  No ___
If yes, please describe: _____________________________________________

What if any experience have you had with death or loss:
_______________________________________________________________

Do you have any apprehensions concerning hospice care?
_______________________________________________________________

Please check classifications of duty you would prefer:
Physical Care of Resident plus Emotional and Spiritual Care as Needed ____
General Household Maintenance ____ Cooking ____ Cleaning ____ Laundry ____
Fund Raiser ____ Other ____________________________________________
Do you have any physical limitations? Yes ________________________ No ____

Please check when you would be available:
7AM - 11AM ____ 11AM- 3PM ____ 3PM-7PM ____ 7PM-11PM ____
SUN ____ MON ____ TUES ____ WEDS ____ THURS ____ FRI ____ SAT ____
Indicate your preference: ____________________________________________

Emergency Phone No: ____________________
References: ____________________________ Tel: ____________________
                     ____________________________ Tel: ____________________

If you are interested in volunteering, please call 585 467 3524 to set up an interview. Feel free to print this application, fill it out and bring it with you to the interview.

Thank you in advance for your interest in volunteering your time.