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Volunteer Application
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Are you retired?
Yes
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Current & Previous Occupation(s)
Volunteer Experience
Pertinent health issues/Physical limitations
Are you currently dealing with someone who is terminally ill?
Direct Patient Support Areas of Interest
Organization Support Areas of Interest
Computer Skills - Check all that apply
Other Computer Skills, Please List
Please provide two references. Include their full name, email address, relationship, and a contact number.
Reference #1 - Name
Name
*
First
Last
Relationship
Email
*
Phone
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Reference #2 - Name
Name
*
First
Last
Relationship
Email
*
Numbers
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Veteran Status
Did you (or your spouse or family member) serve in the military?
Yes
No
Did you serve on active duty?
Yes
No
Did your service include combat, dangerous or traumatic assignments?
Yes
No
Did your spouse serve on active duty?
Yes
No
Do you have any immediate family members that served or are serving in the military?
Yes
No
Comments?
Military Background
In which branch of the military did you serve?
Army
Marines
Navy
Air Force
Coast Guard
Reservist or National Guard
Merchant Marines during WWII
Other
Other, please list:
In which war era or period of service did you serve?
Other, please list:
Overall, how do you view your experience in the military?
Other languages spoken:
Signature
I agree, in typing my First and Last name (below this statement), the information provided in this application is accurate and true to the best of my knowledge. Furthermore, Hospice of the North Coast may use this attestation statement as my electronic signature.
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