Contact Info

First Name* Last Name* Middle

Street Address* City* Zip*

Home Phone:
Work Phone:
Cell Phone:

Your Email*:

How do you prefer to be contacted? Home PhoneWork PhoneCell PhoneEmail

Employment

Current or former occupation:
Current or former employer

How did you hear about Unity?

Why do you want to volunteer for Unity?

Describe any personal experiences you have had with loss

Describe any personal experiences you have had caring for an individual with a serious illness.

Have you had a loved one on Unity's program?

Any specialized training/education/skills/work experience?

Any special interests?

Current/previous involvement or volunteer experience?

Emergency Contacts

First Contact Name

Phone Name

Relationship

Second Contact Name

Phone Name

Relationship

Are you able to make a one-year commitment to volunteering with Unity? YesNo

Generally I am available to volunteer (check all that apply):
morningsafternoonseveningsweekdaysweekends

Generally, what type of work are you drawn to?
patient/family carecreative projectshospice residenceoffice assistancecommunity outreach

To become a Unity Volunteer, each individual must go through a day-long orientation. Please indicate which days you are able to attend:
WeekdaysSaturdays

Special Notes:

References

Reference One Name
Phone
Years known

Reference Two Name
Phone
Years known

Human pop quiz:
What writing utensil uses lead?

Signature

I hereby certify that the answers provided by me are true and correct to the best of my knowledge. I also understand that every applicant will be required to pass a background check and attend orientation prior to becoming an active volunteer. Checking "I agree" below confirms my electronic signature.

I agree