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Applicant Form
Please fill out the form below.
Mailing Address
FIRST NAME
last name
Select one...
Female
Male
Non-Binary
Other
Prefer not to say.
Gender
date of birth
( YYYY/MM/DD )
Basic Information
STREET ADDRESS
CITY
POSTAL CODE
Contact Information
main phone number
mobile/cell number
email address
How did you hear about us?
Anything else you would like us to know?
Languages spoken
Current commitments or obligations
Do you have any physical/health restraints that might affect your volunteer placement? (bad back, hearing, vision)
How do you handle stress?
What interests you in becoming a Hospice Palliative Care volunteer at this time?
Work Background
Allergies
Referral Source
Select one...
Burnaby Hospice Society Website
Charity Village / Volunteer Website
Community Volunteer Organization
Current Volunteer
Fundraiser Event
Newspaper
Other
Personal Loss History
Skills
Emergency Contact
full name
PHONE number
Reference #1
full name
email address
Reference #2
full name
email address
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