| 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 |
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| Date of Birth |
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Present Age |
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| NZ Citzen/Resident? |
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Place of Birth |
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| M/F |
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Are you employed? |
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| Occupation |
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Working full or part time |
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| Previous Jobs / Skills |
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| What religion (if any) do you practice? (answer required in
order to match volunteers with families) |
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| How many hours could you contribute per week? (Minimum 2 hrs excluding
travel) |
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Which days? |
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| 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? |
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| Do you have your own car? And NZ drivers license? |
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What suburbs or how far are you happy
to travel? |
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| Please describe any health problems that may affect your capability
or availability? |
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| 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?) |
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| Have you ever spent time with someone who was sick, dying, or bereaved? |
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| What motivates you to become a volunteer Amitabha Hospice Caregiver? |
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| What would you personally want to gain from this training? |
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| Do you have any previous training related to grief, death, and dying? |
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| Any other skills that you feel you could offer? (e.g. typing, bookkeeping,
translating, fundraising, massage, cooking?) |
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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
By typing in the two words in the box below you help prevent us being spammed. Just
do your best, one word at least should be fairly easy to read.
Thank you!
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