Rockbridge Area Hospice WHV Recognition Volunteer Application

Contact Information

Date of Birth
Country
State / Province*
Address
City
Email*
Confirm Email*
Phone*
Emergency Contact
Emergency Contact Phone Number
Patient/Family Care Interests
  • In Home
  • In Nursing Home
  • In Facility
  • Transportation
  • Meal Delivery
  • Alternative Therapies (music, essential oils, etc.)
  • Other
Non-Patient Services
  • Clerical
  • Fundraising
  • Mailing
  • Events
  • Marketing
  • Answering the Phone
  • Data Entry
  • Other
Other Special Services
  • Manicurist
  • Hairdresser
  • Masseuse
  • Reiki
  • Etc.
Do you know a language other than English?
  • Yes
  • No
If you marked yes, what language?
Check all that apply
  • Speak
  • Read
  • Write
In which branch of military did you serve?
In which era or period of service did you serve?
Are you available on the weekends?
  • Yes
  • No
If you marked yes, what day(s) and time(s)
Generally, how often are you available?
Do you have access to transportation?
  • Yes
  • No
How did you hear about our hospice WHV recognition volunteer program?
Why do you want to be a WHV recognition volunteer?
Additional Comments

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