St Luke’s Hospice West Coast
VOLUNTEER APPLICATION FORM
First Name: Click here to enter text.
Title: Click here to enter text.
Surname: Click here to enter text.
Marital Status: Click here to enter text.
Date of Birth: Click here to enter text.
ID Number: Click here to enter text.
Language (H): Click here to enter text.
Other: Click here to enter text.
Age: Click here to enter text.
Religion: Click here to enter text.
Own Car: Click here to enter text.
Do you have any health related problems?
If yes, please provide details below
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What medication, if any are you presently taking?
Please list below
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Could any of your health related problems impact on your volunteer duties? Please provide details below
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Tel No Home: Click here to enter text.
PERSONAL CONTACT DETAILS
Tel No Work: Click here to enter text.
Mobile No: Click here to enter text.
Email: Click here to enter text.
Physical Address: Click here to enter text.
Postal Address: Click here to enter text.
NEXT OF KIN CONTACT DETAILS
Name of Next of Kin: Click here to enter text.
Relationship to You: Click here to enter text.
Tel Home: Click here to enter text.
Tel Work: Click here to enter text.
OCCUPATION & INTERESTS
Occupation: Click here to enter text.
Qualifications: Click here to enter text.
Career History: Click here to enter text.
Other Skills: Click here to enter text.
Interests/Hobbies: Click here to enter text.
Mobile: Click here to enter text.
VOLUNTEERING FOR HOSPICE
Why would you like to Volunteer? Click here to enter text.
What would you say are your strengths? Click here to enter text.
What do you feel are your weaknesses? Click here to enter text.
How much time are you prepared to commit? Click here to enter text.
How did you hear of St Luke’s Hospice West Coast? Click here to enter text.
PLEASE INDICATE THE AREA IN WHICH YOU WOULD LIKE TO VOLUNTEER BY CLICKING THE BOX
Locum Nursing (Experience needed)
Charity Shops ☐
Reception ☐
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Patient Transport ☐
Spiritual ☐
Companion ☐
Arts & Crafts Click here to enter text.
Catering ☐
Other Click here to enter text.
Bereavement (Course required)
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Patient Day Care (Course required)
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Complimentary Therapies (Details)
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Have you experience a recent bereavement? Explain the circumstances, give dates & relationship of deceased
Have you received counselling, please give details?
Have you received any therapy, please give details?
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For equity/statistical purposes, please indicate in which of the following groups you may fall by clicking the box
Female ☐
Impaired ☐
Disabled ☐
Male ☐
African ☐
Asian ☐
Coloured ☐
FOR OFFICE USE ONLY
Orientation
Placement
Basic Hospice Course
Bereavement
Date
Date
Date
Date
Comments
Comments
Comments
Comments
White ☐