| Name |
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Preferred Name: |
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| Address |
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| Your E-Mail Address: |
|
|
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| Phone: Work |
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Phone: Home |
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| Phone: Mobile |
|
|
|
| Date of Birth |
|
Present Age |
|
| M/F |
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Are you employed? |
|
| Occupation |
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Working full or part time |
|
| Previous Jobs / Skills |
|
| |
| What religion (if any) do you practice? (answer required in
order to match volunteers with families) |
|
| How many hours could you contribute per week? (Minimum 2 hrs excluding
travel) |
|
Which days? |
|
| Do you speak any other languages besides English? |
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Which languages? |
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| What is the source of your emotional or spiritual support in your life? |
|
| Do you have your own car? And NZ drivers license? |
|
What suburbs or how far are you happy
to travel? |
|
| |
| Please describe any health problems that may affect your capability
or availability? |
|
| |
| Have you had a recent bereavement within the last two years? |
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If yes, when and in what relation to you?
(parent, friend, partner, etc?) |
|
| |
| Have you ever spent time with someone who was sick, dying, or bereaved? |
|
| |
| What motivates you to become a volunteer Amitabha Hospice Caregiver? |
|
| |
| What would you personally want to gain from this training? |
|
| |
| Do you have any previous training related to grief, death, and dying? |
|
| |
| Any other skills that you feel you could offer? (e.g. typing, bookkeeping,
translating, fundraising, massage, cooking?) |
|
| |
| Amitabha Hospice complies fully with the Privacy Act. Thank
you for completing this questionnaire. We will contact you for an interview
before the next training program |
| |
|
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